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Fluker SA, Darby R, McDaniel K, Quairoli K, Mbonu C, Kilakkathi S, Koumtouzoua S, Jagannathan R, Miller LS. Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population. Public Health Rep 2024; 139:163-168. [PMID: 37232166 PMCID: PMC10851899 DOI: 10.1177/00333549231170205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.
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Affiliation(s)
- Shelly-Ann Fluker
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Kristi Quairoli
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Collins Mbonu
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sindhu Kilakkathi
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Koumtouzoua
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ram Jagannathan
- Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Lesley S. Miller
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Coyle CR, Desjardins MR, Curriero FC, Rudolph J, Astemborski J, Falade-Nwulia O, Kirk GD, Thomas DL, Mehta SH, Genberg BL. Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD. J Viral Hepat 2023; 30:810-818. [PMID: 37382024 PMCID: PMC10527489 DOI: 10.1111/jvh.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.
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Affiliation(s)
- Catelyn R. Coyle
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Merck & Co. Inc., Rahway, NJ
| | - Michael R. Desjardins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Spatial Science for Public Health Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Frank C. Curriero
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Spatial Science for Public Health Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Jacqueline Rudolph
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Oluwaseun Falade-Nwulia
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David L. Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Shruti H. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Montgomery MP, Randall LM, Morrison M, Gupta N, Doshani M, Teshale E. Hepatitis C Cascades: Data to Inform Hepatitis C Elimination in the United States. Public Health Rep 2023:333549231193508. [PMID: 37667621 DOI: 10.1177/00333549231193508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
The United States has a goal to eliminate hepatitis C as a public health threat by 2030. To accomplish this goal, hepatitis C virus (HCV) care cascades (hereinafter, HCV cascades) can be used to measure progress toward HCV elimination and identify disparities in HCV testing and care. In this topical review of HCV cascades, we describe common definitions of cascade steps, review the application of HCV cascades in health care and public health settings, and discuss the strengths and limitations of data sources used. We use examples from the Massachusetts Department of Public Health as a case study to illustrate how multiple data sources can be leveraged to produce HCV cascades for public health purposes. HCV cascades in health care settings provide actionable data to improve health care quality and delivery of services in a single health system. In public health settings at jurisdictional and national levels, HCV cascades describe HCV diagnosis and treatment for populations, which can be challenging in the absence of a single data source containing complete, comprehensive, and timely data representing all steps of a cascade. Use of multiple data sources and strategies to improve interoperability of health care and public health data systems can advance the use of HCV cascades and speed progress toward HCV elimination.
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Affiliation(s)
- Martha P Montgomery
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Now with Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Liisa M Randall
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Jamaica Plain, MA, USA
| | - Monica Morrison
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Jamaica Plain, MA, USA
| | - Neil Gupta
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mona Doshani
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eyasu Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Sims OT, Truong DN, Wang K, Melton PA, Atim K. Time to HCV Treatment Disfavors Patients Living with HIV/HCV Co-infection: Findings from a Large Urban Tertiary Center. J Racial Ethn Health Disparities 2022; 9:1662-1669. [PMID: 34254269 PMCID: PMC8752646 DOI: 10.1007/s40615-021-01105-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/20/2021] [Accepted: 06/24/2021] [Indexed: 12/09/2022]
Abstract
This study aimed to assess time to hepatitis C (HCV) treatment (i.e., the time between the initial clinic visit for HCV evaluation and the HCV treatment start date), to compare clinical characteristics between patients who received HCV treatment ≥ and < 6 months, and to identify predictors of longer time to HCV treatment in patients living with HCV. This study conducted a retrospective secondary analysis of patients living with HCV mono-infection and HIV/HCV co-infection who received HCV treatment with DAAs (n=214) at a HIV Clinic. Binomial logistic regression was used to identify predictors of longer time to treatment (i.e., ≥ 6 months). The median time to HCV treatment was 211 days. Compared to patients who were treated < 6 months, a higher proportion of patients who were treated ≥ 6 months had HIV/HCV co-infection (31% vs. 49%, p=0.01) and chronic kidney disease (8% vs. 18%, p=0.03). In multivariate analysis, HIV/HCV co-infection was positively associated with a longer time to HCV treatment (adjusted odds ratio, aOR=2.0, p=0.03). Time to HCV treatment disparities between African American and White American did not emerge from the analysis, but time to HCV treatment disfavored patients living with HIV/HCV co-infection. Studies are needed to identify and eliminate factors that disfavor patients living with HIV/HCV co-infection.
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Affiliation(s)
- Omar T Sims
- Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
- Center for AIDS Research, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Integrative Center for Aging Research, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- African American Studies, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California San Francisco, 3137 University Hall, 1720 2nd Avenue South, Birmingham, AL, 35294-1260, USA.
| | - Duong N Truong
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Collat School of Business, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kaiying Wang
- Department of Mathematics and Statistics, College of Arts & Sciences, Georgia State University, Atlanta, GA, USA
| | - Pamela A Melton
- School of Social Work, Tulane University, New Orleans, LA, USA
| | - Kasey Atim
- School of Social Work, University of Alabama, Tuscaloosa, AL, USA
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Alaama AS, Khattabi H, Mugisa B, Atta H, Hermez J, Hutin YJ. Progress towards elimination of viral hepatitis by 2030 in the WHO Eastern Mediterranean Region, 2019. Lancet Gastroenterol Hepatol 2022; 7:862-870. [PMID: 35817075 DOI: 10.1016/s2468-1253(22)00082-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 02/08/2023]
Abstract
The WHO Global Health Sector Strategy and hepatitis regional action plan for the WHO Eastern Mediterranean Region (EMR) proposed strategic directions for countries to progress towards the elimination of viral hepatitis by 2030. In 2019, we reviewed progress to gain a picture of current pressures and identify priority actions for member states to reach this goal. We collected data from country, regional, and global reports published in 2015-19, questionnaires completed by countries, and convened a regional consultation with programme managers and partners. We analysed these data along three thematic areas: governance and finance, strategic information, and service delivery. 15 of the 22 EMR countries completed the review. Of these, 10 (67%) had a national strategy and six (40%) allocated funds to it. 11 (73%) countries had testing and treatment guidelines in line with WHO recommendations. Ten (67%) countries had burden and coverage estimates, four (27%) reported on the cascade of care for hepatitis C virus (HCV), three (20%) reported on the cascade of care for hepatitis B (HBV), and three (20%) had mortality estimates. By 2019, the regional hepatitis B vaccination coverage among infants was 82% for the third dose and 33% for the timely birth dose. For harm reduction, 27 syringes were distributed per injecting drug user per year. Between 2015 and 2019, HCV diagnosis increased from 18% to 33% and treatment for hepatitis C increased from 12% to 26%. Within the same time period, diagnosis of HBV diagnosis increased from 2% to 14% and treatment initiation increased from less than 1% to 2%. EMR countries made progress in governance, policy development, coverage of the third dose of the hepatitis B vaccine, and testing and treatment for HCV infection. However, birth dose vaccination, injection safety, harm reduction, and testing and treatment are limited by insufficient financing. Core interventions need to be included within national universal health coverage packages as an initial move towards elimination.
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Affiliation(s)
- Ahmed Sabry Alaama
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.
| | | | - Bridget Mugisa
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Hoda Atta
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Joumana Hermez
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Yvan J Hutin
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
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Marshall AD, Martinello M, Treloar C, Matthews GV. Perceptions of hepatitis C treatment and reinfection risk among HIV-positive men who have sex with men and engage in high risk behaviours for hepatitis C transmission: The CEASE qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103828. [PMID: 35994937 DOI: 10.1016/j.drugpo.2022.103828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Globally, treatment uptake for hepatitis C virus (HCV) infection among HIV-HCV coinfected men who have sex with men (MSM) has substantially increased since the advent of interferon-free direct-acting antivirals (DAA). However, HIV-positive MSM who engage in high risk behaviours are at an increased risk of HCV reinfection post-treatment. The aim of this study was to investigate perceptions of HCV diagnosis, treatment and reinfection risk among HCV-HIV coinfected MSM who engage in drug use and/or high risk sexual behavior in Sydney, Australia. METHODS Participants were recruited from the Control and Elimination within AuStralia of HEpatitis C from people living with HIV (CEASE) cohort (n=402) who reported engaging in drug use and/or high risk sexual behavior for transmission of HCV infection. Participants were interviewed about their perceptions of HCV diagnosis, treatment, and reinfection risk. Interview data were transcribed, coded, and analyzed thematically. RESULTS Of 33 participants interviewed (mean age 49 years), many participants were 'shocked' by their HCV diagnosis. Participants who believed they acquired HCV infection through sexual exposure felt it was important that their healthcare practitioner agreed with their perspective to mitigate stigmatizing experiences. Overall, participants expressed high satisfaction with their treatment experience due to long-standing therapeutic relationships with their HIV physician. Many participants expressed knowledge of how to prevent HCV reinfection from injection drug use, yet other than condom usage, most were unsure how to reduce high risk sexual activity with such discussions occurring less frequently with healthcare practitioners. CONCLUSION Findings indicate that MSM who engage in drug use and high risk sexual activity would benefit from additional education on reducing reinfection risk through sexual activity and services to reduce substance use, if requested.
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Affiliation(s)
- Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
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Asynchronous electronic consultation between primary care and specialized care proved effective for continuum of care for viraemic hepatitis C patients. GASTROENTEROLOGÍA Y HEPATOLOGÍA 2022; 46:266-273. [PMID: 35964811 DOI: 10.1016/j.gastrohep.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/08/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. METHODS From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. RESULTS From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71-1.99, p<0.001). CONCLUSION Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.
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Genberg BL, Gicquelais RE, Astemborski J, Knight J, Buresh M, Sun J, German D, Thomas DL, Kirk GD, Mehta SH. Trends in fatal and nonfatal overdose by race among people who inject drugs in Baltimore, Maryland from 1998 to 2019. Drug Alcohol Depend 2021; 229:109152. [PMID: 34749056 PMCID: PMC8665116 DOI: 10.1016/j.drugalcdep.2021.109152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study was to examine trends in fatal and nonfatal overdose in a community-based sample of current and former people who inject drugs (PWID). METHODS Data from 4826 current and former PWID from the AIDS Linked to the IntraVenous Experience (ALIVE) observational cohort study in Baltimore, Maryland, were used to characterize fatal and nonfatal overdose rates from 1998 to 2019. Poisson regression was used to examine factors associated with nonfatal overdose and differences by race among 1052 PWID between 2014 and 2019. RESULTS Fatal overdose rates reached a high of 13 per 1000 person-years in 2018. Among 1052 current and former PWID, of whom 75% were Black and one-third were female, the nonfatal overdose rate of 529 per 1000 person-years in 2019 was 8 times higher than 2014 (incidence rate ratio [IRR]=7.76, 95% CI: 3.35, 18.0). The annual adjusted increase in nonfatal overdose rate was 53% among Black PWID (IRR=1.53, 95% CI: 1.34, 1.75), compared to 14% among White PWID (IRR=1.14, 95% CI: 0.88, 1.46). Urban residence, opioid use, depressive symptoms, and hepatitis C infection were positively associated with nonfatal overdose among Black PWID. Recent injection drug use and tranquilizer use was associated with increased overdose among Black and White PWID. CONCLUSIONS Rates of fatal and nonfatal overdose were high and increased from 2014 to 2019 among current and former PWID, with the most dramatic increases in nonfatal overdose observed among Black PWID. These findings highlight the urgent need for additional resources to reduce the differential harms associated with opioids by race.
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Affiliation(s)
- Becky L. Genberg
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Rachel E. Gicquelais
- University of Wisconsin-Madison School of Nursing, 701 Highland Ave, Madison, WI, 53705 USA
| | - Jacquie Astemborski
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Jennifer Knight
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Megan Buresh
- Johns Hopkins School of Medicine, Division of Addiction Medicine, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd floor, Baltimore, MD 21224 USA
| | - Jing Sun
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Danielle German
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - David L. Thomas
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, MD 21205 USA
| | - Gregory D. Kirk
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA, Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, MD 21205 USA
| | - Shruti H. Mehta
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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