Prevalence of Substance Use in an HIV Primary Care Safety Net Clinic: A Call for Screening.

Substance use complicates HIV care and prevention. Primary care clinics are an ideal setting to screen for and offer interventions for unhealthy alcohol and drug use; however, few HIV clinics routinely screen for substance use. We enrolled 208 clinic patients at an urban underserved HIV primary care clinic. We screened the patients for substance use with the Alcohol, Smoking, and Substance Involvement Score Test and measured urine toxicology. Of the 168 participants who completed screening, the majority reported tobacco or nonprescribed substance use in the previous 3 months. More African American participants reported low or no risk amphetamine use compared to Hispanic, White, or Other race participants (p < .001). Implementing standard clinic practice for screening and assessing substance use in HIV primary care clinics is needed

Perspectives on Extended-Release Naltrexone Induction among Patients Living with HIV and Opioid Use Disorder: A Qualitative Analysis

BACKGROUND: The CHOICES study randomized participants with HIV and opioid use disorder (OUD) to HIV clinic-based extended-release naltrexone (XR-NTX), which requires complete cessation of opioid use, versus treatment-as-usual (i.e., buprenorphine, methadone). Study participants randomized to XR-NTX were interviewed to assess their experiences with successful and unsuccessful XR-NTX induction. METHODS: Semi-structured qualitative interviews were completed with a convenience sample of study participants with HIV and OUD (n = 37) randomized to XR-NTX in five HIV clinics between 2018 and 2019. All participants approached agreed to be interviewed. Interviews were digitally recorded, professionally transcribed, and analyzed using thematic analysis. RESULTS: Participants included women (43%), African Americans (62%) and Hispanics (16%), between 27 to 69 years of age. Individuals who completed XR-NTX induction (n = 20) reported experiencing (1) readiness for change, (2) a supportive environment during withdrawal including comfort medications, and (3) caring interactions with staff. Four contrasting themes emerged among participants (n = 17) who did not complete induction: (1) concern and anxiety about withdrawal including past negative experiences, (2) ambivalence about or reluctance to stop opioids, (3) concerns about XR-NTX effects, and (4) preferences for other medications. CONCLUSIONS: The results highlight opportunities to improve initiation of XR-NTX in high-need groups. Addressing expectations regarding induction may enhance XR-NTX initiation rates. Trial Registration ClinicalTrials.gov: NCT03275350. Registered September 7, 2017. https://clinicaltrials.gov/ct2/show/NCT03275350?term=extended+release+naltrexone&cond=Opioid+Use

A delayed injection-site reaction in a patient receiving extended-release naltrexone

BACKGROUND: Pharmacotherapy, such as oral naltrexone, has proven effective in treating alcohol use disorder, although medication adherence has presented challenges. Although a formulation of extended-release naltrexone for intramuscular injection has been developed to counter daily adherence issues, injection-site reactions can occur within days of depot injection. CASE: The authors report a case of an individual with alcohol use disorder who had a previously undescribed delayed injection-site reaction that occurred 11 days after injection. Subsequent challenge with the medication resulted in recurrence of the reaction. DISCUSSION: Although extended-release naltrexone is generally well tolerated, injection-site reactions can complicate treatment and can appear more than 10 days after medication administration

Temporal changes in HCV genotype distribution in three different high risk populations in San Francisco, California

Abstract Background Hepatitis C virus (HCV) genotype (GT) has become an important measure in the diagnosis and monitoring of HCV infection treatment. In the United States (U.S.) HCV GT 1 is reported as the most common infecting GT among chronically infected patients. In Europe, however, recent studies have suggested that the epidemiology of HCV GTs is changing. Methods We assessed HCV GT distribution in 460 patients from three HCV-infected high risk populations in San Francisco, and examined patterns by birth cohort to assess temporal trends. Multiple logistic regression was used to assess factors independently associated with GT 1 infection compared to other GTs (2, 3, and 4). Results Overall, GT 1 was predominant (72.4%), however younger injection drug users (IDU) had a lower proportion of GT 1 infections (54.7%) compared to older IDU and HIV-infected patients (80.5% and 76.6%, respectively). Analysis by birth cohort showed increasing proportions of non-GT 1 infections associated with year of birth: birth before 1970 was independently associated with higher adjusted odds of GT 1: AOR 2.03 (95% CI: 1.23, 3.34). African-Americans as compared to whites also had higher adjusted odds of GT 1 infection (AOR: 3.37; 95% CI: 1.89, 5.99). Conclusions Although, HCV GT 1 remains the most prevalent GT, especially among older groups, changes in GT distribution could have significant implications for how HCV might be controlled on a population level and treated on an individual level

Integrated HIV care is associated with improved engagement in treatment in an urban methadone clinic.

BackgroundPersons living with HIV and unhealthy substance use are often less engaged in HIV care, have higher morbidity and mortality and are at increased risk of transmitting HIV to uninfected partners. We developed a quality-improvement tracking system at an urban methadone clinic to monitor patients along the HIV care continuum and identify patients needing intervention.ObjectiveTo evaluate patient outcomes along the HIV Care Continuum at an urban methadone clinic and explore the relationship of HIV primary care site and patient demographic characteristics with retention in HIV treatment and viral suppression.MethodsWe reviewed electronic medical record data from 2015 for all methadone clinic patients with known HIV disease, including age, gender, race, HIV care sites, HIV care visit dates and HIV viral load. Patients received either HIV primary care at the methadone clinic, an HIV specialty clinic located in the adjacent building, or a community clinic. Retention was defined as an HIV primary care visit in both halves of the year. Viral suppression was defined as an HIV viral load <40 copies/ml at the last lab draw.ResultsThe population (n = 65) was 63% male, 82% age 45 or older and 60% non-Caucasian. Of these 65 patients 77% (n = 50) were retained in care and 80% (n = 52) were virologically suppressed. Viral suppression was significantly higher for women (p = .022) and patients 45 years or older (p = .034). There was a trend towards greater retention in care and viral suppression among patients receiving HIV care at the methadone clinic (93, 93%) compared to the HIV clinic (74, 79%) or community clinics (62, 62%).ConclusionsRetention in HIV care and viral suppression are high in an urban methadone clinic providing integrated HIV services. This quality improvement analysis supports integrating HIV primary care with methadone treatment services for this at-risk population

Integrated HIV care is associated with improved engagement in treatment in an urban methadone clinic.

BackgroundPersons living with HIV and unhealthy substance use are often less engaged in HIV care, have higher morbidity and mortality and are at increased risk of transmitting HIV to uninfected partners. We developed a quality-improvement tracking system at an urban methadone clinic to monitor patients along the HIV care continuum and identify patients needing intervention.ObjectiveTo evaluate patient outcomes along the HIV Care Continuum at an urban methadone clinic and explore the relationship of HIV primary care site and patient demographic characteristics with retention in HIV treatment and viral suppression.MethodsWe reviewed electronic medical record data from 2015 for all methadone clinic patients with known HIV disease, including age, gender, race, HIV care sites, HIV care visit dates and HIV viral load. Patients received either HIV primary care at the methadone clinic, an HIV specialty clinic located in the adjacent building, or a community clinic. Retention was defined as an HIV primary care visit in both halves of the year. Viral suppression was defined as an HIV viral load <40 copies/ml at the last lab draw.ResultsThe population (n = 65) was 63% male, 82% age 45 or older and 60% non-Caucasian. Of these 65 patients 77% (n = 50) were retained in care and 80% (n = 52) were virologically suppressed. Viral suppression was significantly higher for women (p = .022) and patients 45 years or older (p = .034). There was a trend towards greater retention in care and viral suppression among patients receiving HIV care at the methadone clinic (93, 93%) compared to the HIV clinic (74, 79%) or community clinics (62, 62%).ConclusionsRetention in HIV care and viral suppression are high in an urban methadone clinic providing integrated HIV services. This quality improvement analysis supports integrating HIV primary care with methadone treatment services for this at-risk population

Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco

Abstract Background Opioid overdose is a leading cause of death in persons experiencing homelessness (PEH), despite effective medications for opioid use disorder (OUD). In 2016, the San Francisco Street Medicine Team piloted a low barrier buprenorphine program with the primary goal of engaging and retaining PEH with OUD in care as a first step toward reducing opioid use and improving overall health. Objective To characterize the patients; assess treatment retention, retention on buprenorphine, and opioid use; and to describe adverse events. Methods Retrospective chart review of patients receiving at least one buprenorphine prescription from Street Medicine (November 2016–October 2017). We abstracted demographic, medical, substance use, prescription, and health care utilization data from medical records. We assessed retention in care at 1, 3, 6, 9 and 12 months, defined as a provider visit 1 week prior to or any time after each time point. We considered patients to be retained on buprenorphine if they had active buprenorphine prescriptions for more than 2 weeks of the month. We estimated opioid use by the percentage of patients with any opioid-negative, buprenorphine-positive urine toxicology test. We reviewed emergency department and hospital records for adverse events, including deaths and nonfatal opioid overdoses. Results Among the 95 persons eligible for analysis, mean age was 39.2, and 100% reported injecting heroin and homelessness. Medical and psychiatric comorbidities and co-occurring substance use were common. The percentages of patients retained in care at 1, 3, 6, 9 and 12 months were 63%, 53%, 44%, 38%, and 26%, respectively. The percentages of patients retained on buprenorphine at 1, 3, 6, 9 and 12 months were 37%, 27%, 27%, 26%, and 18%, respectively. Twenty-three percent of patients had at least one opioid-negative, buprenorphine-positive test result. One patient died from fentanyl overdose, and four patients presented on six occasions for non-fatal overdoses requiring naloxone. Conclusions This program engaged and retained a subset of PEH with OUD in care and on buprenorphine over 12 months. While uninterrupted treatment and abstinence are reasonable outcomes for conventional treatment programs, intermittent treatment with buprenorphine and decreased opioid use were more common in this pilot and may confer important reductions in opioid and injection-related harms

Injection risk behavior among women syringe exchangers in San Francisco.

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners