Irene Kuo

Background: The HIV Prevention Trials Network 094 INTEGRA study sought to fill the gap in implementation science literature by exploring the delivery of integrated prevention and care for HIV and opioid use dependence through mobile units to people who inject drugs (PWID). Setting: Five US INTEGRA sites with diverse implementation landscapes that were disproportionately affected by the HIV and opioid epidemics (New York; Philadelphia; WA, DC; Houston; and Los Angeles) were included. Methods: In-depth qualitative interviews from an embedded implementation science evaluation were conducted with 37 clinical and research INTEGRA staff delivering integrated care through mobile units. Pragmatic qualitative analysis was guided by the PRISM framework to identify key implementation needs, challenges, and solutions for delivering the INTEGRA intervention via mobile units in local neighborhoods. Results: Staff described how mobile delivery of INTEGRA reduced key barriers that limit PWID’s access to HIV and opioid use dependence services. Yet, they also detailed complex implementation needs, including the proactive coordination among staff to ensure sustained access to INTEGRA services, navigating internal and external spaces to deliver services, maintenance-related demands to keep the mobile unit's infrastructure operational, and interdependent efforts that bridged the mobile unit's service delivery within the extant health systems and community landscapes. Conclusions: Findings demonstrated that mobile integrated care models can reduce access barriers for PWID but require tailored implementation strategies to address operational, spatial, infrastructural, and community-level demands. Results may help inform an implementation blueprint for similar communities working to respond to the intersecting HIV and opioid epidemics affecting PWID across US settings.

Background: Adolescents and young adults account for a disproportionate number of new HIV diagnoses in the United States due to missed opportunities for education, testing, and prevention. Objective: We tested the efficacy of an interactive life-simulation gaming intervention to provide HIV education and improve HIV testing uptake and preventive services among youths ages 13‐24 years in the Washington, DC area. Methods: We conducted a parallel randomized controlled trial testing the efficacy of an HIV-focused gaming intervention app to a control app in increasing HIV testing uptake. Participants were recruited via social media and peer referral. Eligible participants were randomized 1:1 by age (13‐17 vs 18‐24 years) and sexual orientation (lesbian, gay, bisexual, or “other” vs heterosexual). Participants accessed their assigned app for 3 months and completed baseline, 1-, 3-, and 6-month surveys. The primary outcome was self-reported HIV testing within 6 months after enrollment; secondary outcomes included intent to test for HIV, HIV knowledge, and intention to start pre-exposure prophylaxis (PrEP). Analyses were conducted as intent-to-treat and stratified by sexual orientation. Results: From November 2023 to May 2024, we randomized 309 participants (intervention: n=156; control: n=153) with 80% and 88% retention at 6 months, respectively. Among the analyzed participants (intervention: n=150; control: n=149), the mean age was 20.7 (SD 1.84) years, 49% (145/299) were women, and 34% (103/299) were non-Hispanic White. Overall, 53% (158/299) self-reported as gay, lesbian, bisexual, or “other” sexual orientation. A total of 48% (144/299) had previously tested for HIV. Compared to the control app, game participants were 32% less likely to test for HIV within 6 months (relative risk 0.68, 95% CI 0.47‐0.98). The two groups showed no statistically significant differences regarding their intention to get tested for HIV or to start PrEP. A significantly higher difference in mean HIV knowledge scores at 3 months (0.99, 95% CI 0.33‐1.65; P <.01) and 6 months (0.81, 95% CI 0.14‐1.48; P =.02) was observed in the game arm compared to the control arm. Additionally, heterosexual participants in the game arm had statistically significant increases in PrEP intention (0.53, 95% CI 0.05‐1.00; P =.03) across all time points compared to controls. Conclusions: Our interactive gaming app was less effective than an information control app in increasing HIV testing and changing testing and prevention intentions among adolescents and young adults. In the game arm, we did observe increased HIV knowledge and increased PrEP intention among heterosexual adolescents and young adults. Few life-simulation apps integrating HIV testing and prevention features have been rigorously tested among adolescents and young adults. Our efficacy findings suggest that while these interventions are feasible and acceptable to adolescents and young adults, they require additional tailoring to improve their reach, use, and potential effectiveness in real-world settings.

Objectives: To describe HPTN 094 study’s peer navigation (PN) intervention, implemented in 5 urban US cities among people who inject drugs (PWID) at risk for or living with HIV, including guiding theories, core components, navigator training, available services, implementation challenges, and implications for future PN intervention research dissemination. Methods: This 2-arm, randomized, open-label study assessed outcomes for PWID receiving integrated care services delivered in a mobile health unit that provided medication for opioid use disorder (MOUD), HIV prevention/treatment, and other health care in addition to PN to community services compared with PN to community services alone. Participants were PWID with opioid use disorder (OUD) not receiving MOUD and were either at risk for HIV or living with HIV. The PN model was grounded in 5 complementary theories addressing individual, interpersonal, social, systemic, and structural determinants of care. Variables used to measure PN intervention utility were number of sessions attended, session length, session topics, and in-person versus remote navigation sessions. Results: Across study sites, participants without HIV (PWOH; n = 409) completed 3390 PN sessions and participants with HIV (PWH; n = 38) completed 365 PN sessions; the median number of sessions per participant was 6 in both groups. Most sessions were conducted in person and commonly addressed MOUD, HIV prevention or HIV care, and other medical or social service needs. These findings support the feasibility of delivering a flexible, theory-informed PN model for urban PWID and help characterize how peer navigation was used to address substance use, HIV, and broader service needs within HPTN 094. Conclusions: The PN model is acceptable with urban PWID and potentially for people with other public health concerns in underserved communities. The findings have implications for future research examining the effectiveness and dissemination of the PN intervention.

Objective To explore the association of pre-exposure prophylaxis (PrEP) use with condomless sex and sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM) in Washington, DC. Design Multivariate analysis of cross-sectional weighted survey data from 2014, 2017, and 2023 among MSM. Methods: This analysis used venue-based, time-space sampling to survey MSM about HIV-related behavioral risk factors, HIV testing, and use of prevention services. Chi-square tests and logistic regression were conducted to calculate adjusted prevalence ratios (aPR) and ascertain the association between the use of PrEP with condomless sex and having a bacterial STI in the past 12 months Results 774 MSM were surveyed during the three cycles in 2014, 2017, and 2023. The proportion of MSM reporting PrEP use, having a STI in the past 12 months, and condomless sex in the past 12 months increased over time from 2014 to 2023. MSM that used PrEP were more likely to report condomless sex (aPR = 1.33, 95% CI: 1.11–1.55) and having a STI in the past 12 months (aPR = 2.97, 95% CI: 1.35–4.59). Conclusions There is a significant association of PrEP use with both condomless sex and having a STI in the past 12 months among MSM in Washington, DC. As a result, this population may benefit from doxycycline post-exposure prophylaxis (doxy PEP) and other STI prevention methods, but further research is needed to understand the relationship between PrEP, condomless sex, and STIs.

Background: People who inject drugs (PWID) face multilevel barriers to adhering to daily oral preexposure prophylaxis (PrEP). Long-acting injectable (LAI) PrEP may help overcome some of these barriers. Understanding willingness among PWID to take LAI PrEP and preferences for PrEP modality is important to promote LAI PrEP when it becomes available to them. Methods: We analyzed data from the 2018 National HIV Behavioral Surveillance PWID data collection cycle in Washington, DC. Respondent-driven sampling weighted proportions and correlates of willingness to take LAI PrEP and preference for LAI PrEP versus daily oral PrEP were reported, overall and stratified by gender. Results: Of 402 PWID, 69.1% reported being extremely likely/likely to take LAI PrEP; 52.4% preferred LAI PrEP over daily oral PrEP. Being female and uninsured were associated with higher odds of willingness to take LAI PrEP. Having no/low income and past-year sexual violence were associated with preferring LAI PrEP over daily oral PrEP. Men who inject drugs who were aware of PrEP had higher odds to prefer LAI PrEP over daily oral PrEP. Women who inject drugs (WWID) reporting no/low income, sexual violence, and receptive needle sharing were more likely to prefer LAI PrEP over daily oral PrEP. Conclusions: PWID in Washington, DC reported high willingness to take LAI PrEP; half reported preferring LAI PrEP. Improving education about PrEP is important for healthcare providers and PWID. Subgroups of WWID experiencing sexual violence may benefit from LAI PrEP. Human immunodeficiency virus prevention programs for PWID should consider gender differences when implementing LAI PrEP.

Clostridioides difficile infection (CDI) threatens vulnerable populations in health care. Two-step testing improves specificity, avoiding over-treatment. This study analyzed inpatient records to estimate diagnostic outcomes and identify characteristics associated with treatment after discordant testing. Among discordant patients, those aged 65+ years were significantly more likely to be prescribed antibiotics (67% vs 39%).

Rates of hospitalization for bacterial infections due to opioid use disorder (OUD) are rising. Medication for OUD (MOUD) is an evidence-based intervention to treat OUD; however, MOUD initiation during hospitalization remain suboptimal. We aim to understand the continuum of MOUD and impact of MOUD initiation on outcomes of patients hospitalized with infectious complications of OUD. CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers (Figure 1). Patients were hospitalized between 1/1/2018 and 12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data were abstracted regarding demographics, inpatient interventions, transitions of care, and 1 year outcomes. Linear regression model with generalized estimating equation was used to evaluate associations of MOUD initiation with outcomes. 287 patients were predominately male (59%), white (63%), and median age 40 (32;52), with 72 (25%) uninsured, 103 (36%) unstably housed, and 84 (29%) were on MOUD prior to admission. 129 (45%) received MOUD during admission, 113 (39%) had MOUD prescribed on discharge, and 24 (8.4%) were linked to MOUD after admission [fig 2]. During sentinel admission, 62 (22%) were discharged prematurely/eloped, of whom 43 (69%) left without an antibiotic plan. Of the 202 (71%) not on MOUD at baseline, 55 (27%) initiated MOUD during admission. MOUD initiation was associated with higher odds of planned discharge (OR 6.7; p=0.0002) and being discharged on MOUD (OR 174; p< 0.0001) [fig 3]. Being uninsured was associated with lower odds of planned discharge (OR 0.55; < 0.0001) and discharge on MOUD (OR 0.59; p=0.02). CHOICE Baseline Demographics (N=287) Across four healthcare systems, we found that patients hospitalized with infectious complications of OUD had low rates of MOUD initiation and high rates of premature discharge with incomplete ID treatment. Interventions to increase MOUD initiation and expand access to insurance may serve to mitigate the morbidity and mortality associated with OUD-related infections. Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support)

The National Academy of Medicine has identified stigma surrounding substance use disorders (SUDs) and infectious diseases (ID) as a key barrier to integration of opioid use disorder (OUD) and ID services. Prior literature on stigmatizing language in OUD clinical care focuses on surveys and theoretical scenarios rather than real-world data. As part of a larger study of patients admitted for infectious complications of injection drug use (CHOICE), we sought to determine how inpatient physicians describe persons with OUD, as well as associations of this language with outcomes along the OUD continuum of care. CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers. Included patients were hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data was abstracted regarding demographics, inpatient interventions, transitions of care, and outcomes 1 year after admission. Potentially stigmatizing language was identified based on the discharge summary. “Abuse” and “misuse” were considered potentially stigmatizing; “use disorder” was considered best practice. Associations of language and outcomes were analyzed via logistic generalized estimating equations. A total of 287 subjects met inclusion criteria; 119 (42%) were female and the median age was 40 years (IQR: 32 – 52). The most common terms used to describe OUD were “abuse” (190, 66%) and “IVDU” (119, 42%). “Use disorder” was noted in only 72 (25%) charts. In a regression analysis, any mention of “use disorder” was associated with not leaving against medical advice (OR 2.48, 95% CI 1.24 – 4.95), a plan for ongoing OUD treatment (OR 5.17, 95% CI 2.05-13.0), and addiction-specific follow up (OR 2.94, 95% CI 2.34-3.68). In this multicenter retrospective study, inpatient physicians commonly referred to patients with OUD using stigmatizing language. When NIH-preferred language was used this was associated with improved outcomes along the OUD continuum of care, possibly reflecting increased awareness of best practices for treating patients with OUD. Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

Elimination of chronic hepatitis C (HCV) will require scaling up treatment, including possible HCV treatment by primary care providers. The District of Columbia (DC) has a substantial population living with untreated hepatitis C, and treatment expansion would benefit the resident population. The aim of this study was to assess the knowledge, attitudes, and behaviors of primary care providers and specialists related to hepatitis C screening and treatment. We conducted a prospective, online survey of physicians and nurse practitioners (n = 153) in DC on their knowledge, attitudes, and behaviors related to hepatitis C screening and treatment, as well as referral patterns, interest in learning, and preferred learning modalities. We compared responses by provider type. Key findings indicated that HCV screening and treatment knowledge was higher among specialty physicians as compared to primary care providers. The most common reported facilitators of HCV screening included a prompt in the electronic medical record (63%), patient education (57%), and support staff (41%). While 71% reported that HCV treatment was important in the community they serve, only 26% indicated that access to HCV specialist expertise and consultation was a major area of need. Additionally, 59% reported that they refer all HCV patients to specialists for treatment. Primary care providers in DC had moderate interest in learning how to treat chronic hepatitis C, but they need additional training. Patients are typically referred to gastroenterology, infectious diseases, and hepatology specialists who may have limited capacity to expand treatment.