Gregory M. Lucas

Introduction: Syphilis rates have increased in many regions, especially in men who have sex with men (MSM). Yet data are sparse from low- and middle-income countries. We characterized changes in syphilis prevalence across serial respondent-driven sampling surveys in 10 Indian cities between 2012 and 2024. Methods: We used respondent-driven sampling of MSM in 2012–2013 (10 cities), 2016–2017 (same 10 cities), and 2023–2024 (3 of 10 cities). Participants were ≥18 years, male, and reported sex with a man in the prior 12 months. Participants completed a survey, had a rapid HIV antibody test, with reflex HIV RNA and rapid plasma regain confirmed by Treponema pallidum hemagglutination on stored specimens. We assessed syphilis (rapid plasma regain and Treponema pallidum hemagglutination positive) correlates for the 2016–2017 time period using multilevel Poisson regression models, estimating prevalence ratios. Results: Of 9991, 9993, and 2249 participants, median ages were 25, 29, and 28 years, respectively. Almost 50% reported recent condomless anal sex across all rounds. Syphilis prevalence was 2.9%, 7.4%, 15.6% respectively. Less than 10% of participants with positive serology reported a prior diagnosis of syphilis. During the same period, HIV prevalence and viral load suppression doubled. In multivariable analysis, living with HIV (vs. not), ≥2 recent male sexual partners, self-reported history of syphilis, and recent anogenital ulceration was associated with syphilis. Discussion: Syphilis prevalence dramatically increased among MSM over a decade. Concurrently, HIV viremia substantially declined. These data suggest barriers to syphilis testing in urban Indian MSM. Innovations including dual rapid HIV/syphilis antibody tests may increase detection rates.

Chronic hepatitis C infection has been linked to chronic kidney disease. Despite availability of all oral highly curative direct acting antiviral treatment for more than a decade, impact of HCV cure on extrinsically measured iohexol glomerular filtration rate (iGFR), a marker of kidney function, has not been rigorously evaluated. Over two recruitment periods (October 14, 2010 – July 23, 2012 and December 15, 2015 – September 12, 2019), we enrolled 208 participants with chronic HCV infection, 63% of whom were co-infected with HIV. We conducted linear mixed effects modeling to evaluate the change in iGFR slope among participants who were and were not cured from chronic HCV. Secondary outcomes included albuminuria (urine albumin-creatinine-ratio ≥30 mg/g). At baseline, the median age was 51 years (interquartile range: 47–56), most of whom were Black (85%), and male (71%). In the multivariable-adjusted model, including baseline iGFR and other covariates, the adjust difference in iGFR slope was 2.37 mL/min/1.73 m² per year (95% CI: 0.72, 4.03, p = 0.0051) higher among HCV treated participants compared to untreated. HCV treatment status was not associated with probability of albuminuria. Among participants chronically infected with HCV, we identified a significant positive impact of HCV cure on kidney function over time. While iGFR declined overall, declines were attenuated among participants treated for HCV compared to participants who remained untreated.

Aims: The aim of this study was to identify longitudinal trajectories of medication for opioid use disorder (MOUD) use throughout 1 year following MOUD initiation and to examine the association of trajectory membership with HIV testing among people who inject drugs in India.Design, setting and participants: The study comprised group‐based trajectory modeling using longitudinal clinic‐based MOUD use data, set in seven Indian cities with integrated care centers (ICC) delivering MOUD, predominantly buprenorphine, in 2018−2019. A total of 1562 people who inject drugs who initiated MOUD for the first time at an ICC between 1 January 2018 and 31 December 2018 were included in this study. Median age was 26 years, 98% were male and 22% were living with HIV.Measurements: Daily directly observed MOUD visits were biometrically verified and entered into an electronic database. A dichotomous variable for MOUD use each day throughout 1 year following initiation was created for the trajectory models. Client socio‐demographics, HIV status and testing at the ICC and dose were extracted from the clinical database.Findings: We found five MOUD trajectory groups: (1) early dropout (41%), (2) late dropout (18%), (3) delayed dropout (10%), (4) intermittent use (12%) and (5) persistent use (19%). Differences between the dropout groups were characterized by the rate of decline in MOUD use over time. The late dropout group had an 18% higher rate of HIV testing [adjusted rate ratio (aRR) = 1.18, 95% confidence interval (CI) = 1.10–1.27] and those with persistent MOUD use had a 91% higher rate of testing (aRR = 1.91, 95% CI = 1.77–2.05) compared with the early dropout group.Conclusions: Nearly 70% of clients initiating medication for opioid use disorder (MOUD) at integrated care centers (ICCs) in India stop MOUD use within 1 year, with trajectories characterized by the rate of decline in engagement. Clients with better MOUD adherence appear to return more frequently for HIV testing at the ICCs, underscoring the value of integrated care models.

Introduction: Globally, there have been significant declines in HIV incidence over the past two decades, but this decline is slowing, and in some settings, declines have stalled or are growing—particularly where epidemics are concentrated in key populations (KPs). Understanding temporal changes in HIV incidence among KP is critical yet, due to logistical constraints, there are few sources of longitudinal incidence data, particularly among KP.Methods: We present HIV incidence rates from June 2014 to December 2022 among cisgender men who have sex with men (MSM) and people who inject drugs (PWID) attending community‐based integrated care centres (ICCs) in 15 Indian cities. ICCs, established between 2014 and 2017, provide HIV testing and other services to MSM (eight sites) or PWID (eight sites). Client HIV testing data were included in the analysis if they had ≥2 tests and were not positive on the first test. We calculated incidence rates per 100 person‐years (PY), stratified by KP, city/site and year. Poisson regression explored associations of incidence with time, age, gender (PWID only) and ICC use.Results: From June 2014 to December 2022, 13,501 clients (5722 MSM, 7779 PWID) had ≥2 HIV tests over a median of 1.8 years. There were a total of 1093 incident HIV acquisitions. Overall incidence rates for MSM and PWID were 1.9/100 PY (95% CI: 1.7−2.2) and 4.1 (3.9−4.4), respectively. Among MSM sites, incidence ranged from 0.4 to 3.5 and in PWID sites from 0.6 to 17.9. From adjusted models, incidence increased by 17% annually among MSM. Among PWID, incidence increased by 11% annually up until 2020 and then decreased by 29% after 2020; when excluding the outlier of New Delhi, incidence was stable among PWID. MSM and PWID 21−25 years old had the highest risk of HIV and among PWID, those more consistently engaged in medication for opioid use disorder were at the lowest risk.Conclusions: While there was substantial geographic variability, MSM and PWID engaged in a free community‐based clinic experienced persistently high HIV incidence (>2/100 PY). KP in low‐ and middle‐income countries should be a focus when considering novel strategies such as long‐acting pre‐exposure prophylaxis to curtail incidence.

Background: Hepatitis C virus (HCV) infection and hazardous alcohol use are both preventable causes of morbidity and mortality among people who inject drugs (PWID). In the general population, hazardous alcohol is associated with a reduced likelihood of HCV treatment initiation. Less is known about the prevalence and impact of hazardous alcohol use on direct-acting antiviral (DAA) therapy initiation among PWID with active injection drug use. Methods: PWID were recruited via street outreach in Baltimore, Maryland, between 2018 and 2019 and were enrolled in a study cohort. Participants completed a study survey and underwent HCV testing. Self-reported DAA therapy initiation was evaluated at follow-up visits every six months. Hazardous alcohol use was determined based on an AUDIT-C score of ≥4 for men or ≥3 for women. Data were analyzed using multivariable logistic regression with generalized estimating equations. Results: Of the 720 PWID recruited, 291 had detectable HCV RNA, and only 134 were aware of their HCV infection. The mean (±standard deviation) age of those that were aware of their infection was 48.7 (±10.3) years, with a slight majority (53.0%) being male and predominantly African American (64.9%). The majority (80/134, 59.7%) met criteria for hazardous alcohol use. Only 16 (11.9%) PWID reported DAA therapy initiation within six months, and 20 (14.9%) reported it within 12 months of follow-up. Hazardous alcohol use (aOR = 1.23, 95% CI = 0.43–3.53) was not associated with DAA treatment initiation. Conclusions: There was a high prevalence of hazardous alcohol use, low rates of oral DAA therapy initiation, and no association between self-reported hazardous alcohol use and initiation of oral DAA therapy in our sample of PWID that were aware of their chronic HCV infection. Strategies to increase HCV treatment uptake in PWID with active drug use are urgently needed and should integrate alcohol and drug use evaluation and care.

Introduction: Injection drug networks may influence their network members’ health‐seeking behaviours. Using data from a sociometric injecting partner network of people who inject drugs (PWID) in New Delhi, India, we assessed the role of injecting partner (alter) behaviours on individual engagement in HIV prevention services.Methods: We enumerated injecting partner linkages among 2512 PWID using coupon referrals and biometric data from November 2017 to March 2020. Participants completed interviewer‐administered questionnaires and provided information on injection behaviours, injecting partners, HIV/hepatitis C (HCV) testing and service engagement. Multilevel multiple‐membership models (MMMM) evaluated individual PWID HIV testing, medication for opioid use disorder (MOUD) and syringe service engagement as a function of alter attributes, accounting for membership across multiple ego‐networks. Logistic regression models assessed parallel associations among socially proximal injecting peers, defined as PWID ≤3 path length from ego.Results: Median age was 26 years; 99% were male. PWID had median 2 injecting partners and 8 socially proximal peers; 14% reported HIV testing, 33% accessed MOUD and 13% used syringe services 6 months prior. In MMMM analyses, PWID with ≥1 versus 0 injecting partners who received HIV testing were significantly more likely to report HIV testing (adjusted odds ratio [aOR]: 2.27, 95% confidence interval [CI]: 1.68–3.16), MOUD (aOR: 1.99, 95% CI: 1.60–2.53) and syringe service use (aOR: 1.66, 95% CI: 1.21–2.39). We observed similar findings for individual MOUD and syringe service use. Having ≥1 versus 0 HIV‐positive partners was associated with decreased HIV testing and MOUD but increased syringe service use (aOR: 1.54, 95% CI: 1.09–2.17). PWID with ≥1 versus 0 socially proximal peers who used non‐sterile injection equipment reported increased HIV testing (aOR: 1.39, 95% CI: 1.01–1.92), MOUD (aOR: 1.40, 95% CI: 1.10–1.77) and syringe service use (aOR: 1.82, 95% CI: 1.23–2.68).Conclusions: We found differential associative relationships between individual HIV prevention service engagement and the health or risk behaviours of direct and indirect alters. Characterizing network exposure beyond direct injecting partnerships provided important context on possible mechanisms of behavioural influence. Findings could be leveraged to design peer‐based interventions that promote network diffusion of health‐seeking behaviours.

Background and aims: People who inject drugs (PWID) are at risk for adverse outcomes across multiple dimensions. While evidence‐based interventions are available, services are often fragmented and difficult to access. We measured the effectiveness of an integrated care van (ICV) that offered services for PWID.Design, setting and participants: This was a cluster‐randomized trial, which took place in Baltimore, MD, USA. Prior to randomization, we used a research van to recruit PWID cohorts from 12 Baltimore neighborhoods (sites), currently served by the city's mobile needle exchange program.Intervention and comparator: We randomized sites to receive weekly visits from the ICV (n = 6) or to usual services (n = 6) for 14 months. The ICV offered case management; buprenorphine/naloxone; screening for HIV, hepatitis C virus and sexually transmitted infections; HIV pre‐exposure prophylaxis; and wound care.Measurements: The primary outcome was a composite harm mitigation score that captured access to evidence‐based services, risk behaviors and adverse health events (range = 0−15, with higher numbers indicating worse status). We evaluated effectiveness by comparing changes in the composite score at 7 months versus baseline in the two study arms.Findings: We enrolled 720 cohort participants across the study sites (60 per site) between June 2018 and August 2019: 38.3% women, 72.6% black and 85.1% urine drug test positive for fentanyl. Over a median of 10.4 months, the ICV provided services to 734 unique clients (who may or may not have been cohort participants) across the six intervention sites, including HIV/hepatitis C virus testing in 577 (78.6%) and buprenorphine/naloxone initiation in 540 (74%). However, only 52 (7.2%) of cohort participants received services on the ICV. The average composite score decreased at 7 months relative to baseline, with no significant difference in the change between ICV and usual services (difference in differences: −0.31; 95% confidence interval: −0.70, 0.08; P = 0.13).Conclusions: This cluster‐randomized trial in Baltimore, MD, USA, found no evidence that weekly neighborhood visits from a mobile health van providing injection‐drug‐focused services improved access to services and outcomes among people who injected drugs in the neighborhood, relative to usual services. The van successfully served large numbers of clients but unexpectedly low use of the van by cohort participants limited the ability to detect meaningful differences.

People who inject drugs (PWID) have a high prevalence of hepatitis C virus (HCV) infection. However, HCV treatment rates among PWID remain low. Previous data suggest that hazardous alcohol use is negatively associated with direct-acting antiviral (DAA) therapy initiation in the general population. We aimed to evaluate the effect of hazardous alcohol use on DAA therapy initiation among PWID. PWID were recruited through street outreach in Baltimore, Maryland 2018–2019. Participants completed a study survey and HCV testing (antibody reflex to RNA) at study visits. DAA initiation (self-report) was assessed at study follow-up in 6-month increments. Hazardous alcohol use was defined as Alcohol Use Disorders Identification Test-C (AUDIT-C) ≥4 for men or ≥3 for women. Frequency of injection drug use was categorized as ≤3 vs. >3 times/day. Longitudinal data were analyzed using descriptive statistics and multivariable logistic regression analyses with generalized estimating equations (GEE). Among our sample of PWID with HCV infection, oral DAA treatment was not associated with self-reported hazardous alcohol use. The overall very low rates of HCV treatment are concerning and need to be addressed by effective interventions, especially for younger PWID. Oluwaseun Falade-Nwulia, MBBS ,MPH, Abbvie Inc: Grant/Research Support|Gilead Sciences: Advisor/Consultant

Of 3.5 million people living with HCV in the US, nearly 60% are people who inject drugs (PWID). Despite the availability of a cure for HCV, uptake remains low in PWID. We set out to study the social determinants of health (SDOH) that impact the HCV care cascade. We conducted a secondary analysis of baseline data from 720 PWID in a cluster-randomized trial. We recruited PWID via an outreach van from 12 drug-affected areas in Baltimore City. Inclusion criteria included injection in the prior month or needle sharing in the past 6 months. An intake visit included a survey and a blood draw for HCV testing (serology reflexed to HCV RNA). Focusing on SDOH, we analyzed factors related to self-report of i) awareness of HCV infection (in the subgroup with active or treated HCV) and ii) prior HCV treatment (in the subgroup that was aware of their HCV infection). We used descriptive statistics and logistic regression for statistical analyses. The 342 PWID included in our study had a median age of 52 years and most were male and Black. 53% injected daily and 67% reported receptive needle sharing in the past 6 months. Of 251 who were aware of their HCV infection, 34% reported treatment. In this study of street recruited PWID, we observed a lower treatment uptake in women despite greater HCV infection awareness. SDOH categories with significant associations to the HCV care cascade included finances, stigma, support system, healthcare usage, and housing status. Strategies to not only identify but address SDOH are vital to end HCV. Oluwaseun Falade-Nwulia, MBBS ,MPH, Abbvie Inc: Grant/Research Support|Gilead Sciences: Advisor/Consultant