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Abstract Background Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility. Methods This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states—Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars. Results State-level average and median start-up cost (representing 8–10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost. Conclusion We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.

Abstract Background People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP). Methods The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs. Discussion The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are. Trial Registration: ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Abstract Background Currently, there are more than two million people in prisons or jails, with nearly two-thirds meeting the criteria for a substance use disorder. Following these patterns, overdose is the leading cause of death following release from prison and the third leading cause of death during periods of incarceration in jails. Traditional quantitative methods analyzing the factors associated with overdose following incarceration may fail to capture structural and environmental factors present in specific communities. People with lived experiences in the criminal legal system and with substance use disorder hold unique perspectives and must be involved in the research process. Objective To identify perceived factors that impact overdose following release from incarceration among people with direct criminal legal involvement and experience with substance use. Methods Within a community-engaged approach to research, we used concept mapping to center the perspectives of people with personal experience with the carceral system. The following prompt guided our study: “What do you think are some of the main things that make people who have been in jail or prison more and less likely to overdose?” Individuals participated in three rounds of focus groups, which included brainstorming, sorting and rating, and community interpretation. We used the Concept Systems Inc. platform groupwisdom for our analyses and constructed cluster maps. Results Eight individuals (ages 33 to 53) from four states participated. The brainstorming process resulted in 83 unique factors that impact overdose. The concept mapping process resulted in five clusters: (1) Community-Based Prevention, (2) Drug Use and Incarceration, (3) Resources for Treatment for Substance Use, (4) Carceral Factors, and (5) Stigma and Structural Barriers. Conclusions Our study provides critical insight into community-identified factors associated with overdose following incarceration. These factors should be accounted for during resource planning and decision-making.

Opioid-related overdose deaths have increased since 2010 in the U.S., but information on trends in opioid use disorder (OUD) prevalence is limited due to unreliable data. Multiplier methods are a classical epidemiological technique to estimate prevalence when direct estimation is infeasible or unreliable. We used two different multiplier approaches to estimate OUD prevalence from 2010 to 2019. First, we estimated OUD in National Survey on Drug Use and Health (NSDUH), and based on existing capture-recapture studies, multiplied prevalence by 4.5x. Second, we estimated the probability of drug poisoning death among people with OUD (Meta-analysis indicates 0.52/100,000), and divided the number of drug poisoning deaths in the US by this probability. Estimates were weighted to account for increase in drug-related mortality in recent years due to fentanyl. Estimated OUD prevalence was lowest when estimated in NSDUH with no multiplier, and highest when estimated from vital statistics data without adjustment. Consistent findings emerged with two methods: NSDUH data with multiplier correction, and vital statistics data with multiplier and adjustment. From these two methods, OUD prevalence increased from 2010 to 2014; then stabilized and slightly declined annually (survey data with multiplier, highest prevalence of 4.0% in 2015; death data with a multiplier and correction, highest prevalence of 2.35% in 2016). The number of US adolescent and adult individuals with OUD in 2019 was estimated between 6.7–7.6 million. When multipliers and corrections are used, OUD may have stabilized or slightly declined after 2015. Nevertheless, it remains highly prevalent, affecting 6–7 million US adolescents and adults.

Abstract Introduction An estimated 6 million Americans have Alzheimer's disease (AD). Aducanumab was recently approved by the Food and Drug Administration despite the lack of clinical effectiveness data. Methods We developed a Markov state transition model of AD to estimate the cost effectiveness of aducanumab compared to standard of care (SOC) over a 5‐year time horizon for a cohort of persons aged 65 with mild AD. Outcomes included quality adjusted life years (QALYs), discounted costs, and incremental cost‐effectiveness ratios (ICERs). We performed sensitivity analyses to address uncertainty. Results Over 5 years, the incremental cost of aducanumab compared to SOC was $179,890. Aducanumab resulted in 0.47 QALYs gained compared to SOC. The ICER for aducanumab compared to SOC was $383,080/QALY. In threshold analysis, aducanumab became cost‐effective at $22,820/year. Discussion Aducanumab is not cost‐effective at the estimated price of $56,000 even under ideal circumstances in which it completely halts AD progression.

Summary: Background: Innovations are needed to increase universal HIV screening by primary care providers. One potential intervention is self-audit feedback, which describes the process of a clinician reviewing their own patient charts and reflecting on their performance. Methods: The effectiveness of self-audit feedback was investigated using a mixed methods approach. A total of 2111 patient charts were analyzed in a quantitative pre-post intervention study design, where the intervention was providing self-audit feedback to all internal medicine residents at one institution through an annual chart review. Qualitative data generated from the subsequent resident focus group discussions explored the motivation and mechanism for change using a knowledge–attitude–behavior framework. Results: The proportion of primary care patients screened for HIV increased from 17.9% (190/1060) to 40.3% (423/1051). The adjusted odds ratio of a patient being screened following resident self-audited feedback was 3.17 (95% CI 2.11, 4.76, p

Abstract Background The number of people experiencing unsheltered homelessness in the U.S. is increasing. Municipalities have responded with punitive responses such as involuntary displacement (i.e., encampment sweeps, move along orders), but little is known about the impact of involuntary displacement on health. The purpose of this study was to investigate the association between broadly defined experiences of involuntary displacement and self-reported health conditions among people experiencing homelessness. Methods We used logistic regression models to generate odds ratios using publicly available data from a cross-sectional sample of people experiencing homelessness in Denver, Colorado, during September 2018-February 2019. Hosmer-Lemeshow Goodness of Fit tests were used to assess model fit. Results Among 397 people experiencing homelessness, involuntary displacement was significantly associated with self-reported infectious diseases (adjusted odds ratio (aOR) 2.09, 95% CI 1.27, 3.41), substance and alcohol use (aOR 2.83; 95% CI 1.70, 4.73), climate-related conditions (aOR 2.27; 95% CI 1.35, 3.83), and worsening mental health (aOR 2.00; 95% CI 1.24, 3.24) after controlling for potential confounders. No statistically significant associations were identified between involuntary displacement and injuries, musculoskeletal issues, chronic conditions, and chronic mental and emotional issues. Conclusions This research quantifies the association between involuntary displacement and multiple infectious and non-infectious health outcomes. While city officials attempt to grapple with increasing unsheltered homelessness, it is important to understand what harms are occurring that are associated with current policies. Our research adds to the growing body of literature that involuntary displacement is a harmful response to unsheltered homelessness. Alternative approaches focused on connections to housing and social services should be prioritized.

IntroductionAddiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD.MethodsWe developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards.ResultsThere were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity.DiscussionOur novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.

Background and aimsLiver disease in people living with HIV co-infected with hepatitis C virus is a source of morbidity and mortality in Russia. HIV accelerates liver fibrosis in the setting of HCV co-infection and alcohol use. Zinc deficiency is common among people living with HIV and may be a factor that facilitates the underlying mechanisms of liver fibrosis. We investigated the association between zinc deficiency and advanced liver fibrosis in a cohort of HIV/HCV co-infected persons reporting heavy drinking in Russia.MethodsThis is a secondary data analysis of baseline data from 204 anti-retroviral treatment naïve HIV/HCV co-infected Russians with heavy drinking that were recruited into a clinical trial of zinc supplementation. The primary outcome of interest in this cross-sectional study was advanced liver fibrosis. Zinc deficiency, the main independent variable, was defined as plasma zinc ResultsThe prevalence of advanced liver fibrosis was similar for those with zinc deficiency compared to those with normal zinc levels, (27.7% vs. 23.0%, respectively). We did not detect an association between zinc deficiency and advanced liver fibrosis in the adjusted regression model (aOR: 1.28, 95% CI: 0.62-2.61, p = 0.51) nor in exploratory analyses.ConclusionsIn this cohort of Russians with HIV/HCV co-infection, who are anti-retroviral treatment naïve and have heavy alcohol use, we did not detect an association between zinc deficiency or zinc levels and advanced liver fibrosis.

Objectives: To estimate the annual prevalence of opioid use disorder (OUD) in Massachusetts from 2011 to 2015., Methods: We performed a multisample stratified capture-recapture analysis to estimate OUD prevalence in Massachusetts. Individuals identified from 6 administrative databases for 2011 to 2012 and 7 databases for 2013 to 2015 were linked at the individual level and included in the analysis. Individuals were stratified by age group, sex, and county of residence., Results: The OUD prevalence in Massachusetts among people aged 11 years or older was 2.72% in 2011 and 2.87% in 2012. Between 2013 and 2015, the prevalence increased from 3.87% to 4.60%. The greatest increase in prevalence was observed among those in the youngest age group (11-25 years), a 76% increase from 2011 to 2012 and a 42% increase from 2013 to 2015., Conclusions: In Massachusetts, the OUD prevalence was 4.6% among people 11 years or older in 2015. The number of individuals with OUD is likely increasing, particularly among young people.

In 2012 the Centers for Disease Control and Prevention recommended routine testing for hepatitis C for people born in the period 1945-65. Until now, the recommendation's impact on hepatitis C screening rates in the United States has not been fully understood. We used an interrupted time series with comparison group design to analyze hepatitis C screening rates in the period 2010-14 among 2.8 million commercially insured adults in the MarketScan database. Hepatitis C screening rates increased yearly between 2010 and 2014, from 1.65 to 2.59 per 100 person-years. A 49 percent increase in screening rates among people born during 1945-65 followed the release of the recommendation, but no such increase was observed among adults born after 1965. The effect among the target population was sustained, and by twenty-four months after the recommendation's release, screening rates had increased 106 percent. We conclude that the hepatitis C testing policy change resulted in significantly increased testing among the target population and may have decreased the magnitude of the hepatitis C epidemic.