BackgroundPeople who inject drugs are at a disproportionate risk for contracting hepatitis C virus (HCV). However, use of HCV prevention and treatment services remains suboptimal among people with substance use disorders due to various health system, societal, and individual barriers. Mobile health applications offer promising strategies to support people in recovery from substance use disorders. We sought to determine whether the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), an existing mobile health application for opioid use disorder, could be adapted to improve HCV screening and treatment.ObjectiveThe goals of this paper are to describe: (1) the components and functionality of an HCV intervention incorporated into the existing A-CHESS system; and (2) how data are collected and will be used to evaluate HCV testing, linkage to care, and treatment.MethodsPeople with recent opioid use were enrolled in a randomized controlled trial to test whether A-CHESS reduced relapse. We developed and implemented HCV intervention content within the A-CHESS platform to simultaneously evaluate whether A-CHESS improved secondary outcomes related to HCV care. All A-CHESS users received the HCV intervention content, which includes educational information, private messages tailored to an individual’s stage of HCV care, and a public discussion forum. Data on patients’ HCV risk behaviors and stage of care were collected through quarterly telephone interviews and weekly surveys delivered through A-CHESS. The proportion of people with opioid use disorder who are HCV untested, HCV-negative, HCV antibody-positive, or HCV RNA–positive, as well as linked to care, treated and cured at baseline is described here. The 24-month follow-up is ongoing and will be completed in April 2020. Survey data will then be used to assess whether individuals who received the HCV-enhanced A-CHESS intervention were more likely to reduce risky injection behaviors, receive HCV testing, link to medical care, initiate treatment, and be cured of HCV compared to the control group.ResultsBetween April 2016 and April 2018, 416 individuals were enrolled and completed the baseline interview. Of these individuals, 207 were then randomly assigned to the control arm and 209 were assigned to the intervention arm. At baseline, 202 individuals (49%) self-reported ever testing HCV antibody-positive. Of those, 179 (89%) reported receiving HCV RNA confirmatory testing, 134 (66%) tested HCV RNA–positive, 125 (62%) were linked to medical care and 27 (13%) were treated and cured of HCV. Of the remaining 214 individuals who had never tested HCV antibody–positive, 129 (31%) had tested HCV antibody–negative within the past year and 85 (20%) had not been tested within the past year.ConclusionsThe A-CHESS mobile health system allows for the implementation of a bundle of services as well as the collection of longitudinal data related to drug use and HCV care among people with opioid use disorders. This study will provide preliminary evidence to determine whether HCV-specific services embedded into the A-CHESS program can improve HCV outcomes for people engaged in addiction treatment.Trial RegistrationClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034International Registered Report Identifier (IRRID)DERR1-10.2196/12620

This paper uses GARCH models and daily data to investigate the effect of the Canada – U.S. Free Trade Agreement (CUSFTA) and NAFTA on the volatility of, and the relationship between stock market returns and changes in bilateral exchange rates of the member countries. Empirical results indicate that the CUSFTA had a stabilizing effect on the Canadian and U.S. equity markets while increasing the volatility of the CAD/USD exchange rate. NAFTA further reduced the two stock markets’ volatility, however unlike CUSFTA, NAFTA also reduced the volatility of the CAD/USD exchange rate. Additional results indicate that during NAFTA, the Mexican stock market is more volatile than the other stock and bilateral exchange markets. Moreover, the exchange rate of the Mexican peso against both the U.S. and Canadian dollars has been more volatile than the Canadian dollar/US dollar exchange rate. Evidence also suggests that all three stock markets are positively correlated with each other with the U.S. market being much less correlated with the Canadian and Mexican stock markets than the latter two markets are correlated with each other. Evidence found in this paper suggests a negative relationship between the stock and bilateral currency markets that is statistically significant except for the U.S. equity market when paired with an exchange rate that involves the Mexican peso.

Geosocial networking (GSN) applications could disseminate HIV prevention information to thousands of men who have sex with men (MSM); however, acceptability of the type of information, methods, and frequency of information delivery are unknown. Acceptability of these constructs were assessed through a survey of 224 MSM at the Milwaukee Pridefest. All types of information were found acceptable. A sexual health section and self-seeking information were the most acceptable method and frequency of delivery. Demographics and differences in app usage did not correlate to acceptability. Continued research focusing on the feasibility of incorporating HIV prevention information into GSN applications is needed.

Because many people who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) and have poor access to medical care, many HCV-infected PWID remain undiagnosed and unaccounted for in surveillance systems. Syringe exchange programs (SEPs) are an under-utilized resource for collecting information missing from surveillance systems. Partnerships with public health agencies represent a potentially innovative approach to studying the HCV epidemic for PWID. The goal of this study was to characterize the HCV care continuum for a cohort of PWID using database linkages.

CDC's 2012 Hepatitis Testing and Linkage to Care (HepTLC) initiative was a nationally coordinated effort to conduct hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites. This project provided support for data management and monthly data reviews between awardees and a data manager, which facilitated monitoring of awardee progress and regular program improvement opportunities. CDC provided technical assistance to awardees for testing processes and program improvement, including Internet-based data submission, reporting software and data management to awardees, offering assistance with submitting, and reviewing data in real time. We describe how one awardee, AIDS Resource Center of Wisconsin (ARCW), used the data management process to improve data quality, inform testing processes and implementation, and measure and report missing variables from an online database. From October 2012 through July 2014, ARCW performed 2,255 HCV antibody (anti-HCV) tests and 244 HCV ribonucleic acid (RNA) tests as part of the HepTLC initiative. Participants who tested HCV RNA positive (n=189) were referred to medical care. At the end of the study, no records were missing for the anti-HCV test result or HCV RNA test result variables, and only one record was missing for those who were referred to medical care. Regular data review and monitoring by awardees and CDC-supported data managers provided opportunities for data quality and program improvement. Through regular data review, ARCW reduced the amount of missing data and promoted timely follow-up with participants testing positive for HCV to ensure receipt of results and linkage to care. Other programs can adopt a similar data management model.

HIV testing promotion is a critical HIV prevention strategy, especially among at-risk groups such as young men who have sex with men (YMSM). Based on a web survey of 194 YMSM (18-24), we examine the association of social network characteristics and functions, and of individual-level characteristics, with three HIV testing behaviors (ever, repeat, and recent testing). Network homophily was associated with recent testing in multivariable models. The network function of information acquisition was associated with ever testing and repeat testing. Perceived stigma regarding HIV-related help-seeking was negatively related to recent testing. Individual characteristics were associated with testing outcomes in all models; age, perceived behavioral control, and positive attitudes had the greatest influence. Individual characteristics had a stronger association with ever testing and repeat testing than network characteristics and functions; however, this relationship was reversed for recent testing. Findings support the value of multi-level and network-focused interventions for promoting HIV testing among YMSM.

BackgroundHepatitis C virus (HCV) infection is a growing problem among people who inject drugs. Strategies to reduce disease transmission (eg, syringe exchange programs) and facilitate HCV screening and linkage are available but are under-utilized in many communities affected by injection drug use. Novel approaches to increasing the use of these strategies are needed.ObjectiveThe goals of this project are to (1) develop and pilot test a computerized tailored intervention for increasing HCV screening and decreasing risky drug use behavior among people who inject drugs and (2) determine the feasibility of disseminating such an intervention using peer-based referrals in the setting of a community-based syringe exchange program.MethodsThis 2-arm, randomized pilot study is being conducted in a large-volume, multisite syringe exchange program in southern Wisconsin. A social network–based strategy was used to recruit a total of 235 adults who reported past-month injection of opioids, cocaine, or methamphetamine. Network recruiters were identified among clients requesting services from the syringe exchange program and were enlisted to refer eligible peers to the study. All participants completed a computer-adapted questionnaire eliciting information about risk behaviors and their knowledge, attitudes, and prior experiences related to HCV screening. Subjects were then randomly assigned to receive usual care, consisting of standard counseling by syringe exchange staff, or the Hep-Net intervention, which provides algorithm-based, real-time tailored feedback and recommendations for behavior change in the style of motivational interviewing. Changes in drug use behaviors and attitudes will be assessed during a second session between 90 and 180 days after the baseline visit. Frequency of repeat HCV testing and HCV incidence will be assessed through a database search 1 year after study completion.ResultsRecruitment for this study was completed in April 2015. Follow-up of enrolled participants is expected to continue until March 2016. Network recruiters were enrolled who referred a total of 195 eligible peers (overall N=235). At baseline, the median age was 34 years; 41.3% (97/235) were non-white; and 86.4% (203/235) reported predominantly injecting heroin. Most participants (161/234, 68.8%) reported sharing injection equipment in the past and of these, 30.4% (49/161) had never been tested for HCV.ConclusionsThis study will provide preliminary evidence to determine whether incorporating computerized behavioral interventions into existing prevention services at syringe exchange programs can lead to adoption of healthier behaviors.Trial RegistrationClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043 (Archived by WebCite at http://www.webcitation.org/6dbjUQG7J)

Structural characteristics are linked to HIV/STI risks, yet few studies have examined the mechanisms through which structural characteristics influence the HIV/STI risk of young men who have sex with men (YMSM). Using data from a cross-sectional survey of YMSM (ages 18-29) living in Detroit Metro (N=328; 9% HIV-positive; 49% Black, 27% White, 15% Latino, 9% Other race), we used multilevel modeling to examine the association between community-level characteristics (e.g., socioeconomic disadvantage; distance to LGBT-affirming institutions) and YMSM's HIV testing behavior and likelihood of engaging in unprotected anal intercourse with serodiscordant partner(s). We accounted for individual-level factors (race/ethnicity, poverty, homelessness, alcohol and marijuana use) and contextual factors (community acceptance and stigma regarding same-sex sexuality). YMSM in neighborhoods with greater disadvantage and nearer to an AIDS Service Organization were more likely to have tested for HIV and less likely to report serodiscordant partners. Community acceptance was associated with having tested for HIV. Efforts to address YMSM's exposure to structural barriers in Detroit Metro are needed to inform HIV prevention strategies from a socioecological perspective.

BackgroundIncarceration is common among people who inject drugs. Prior research has shown that incarceration is a marker of elevated risk for opioid overdose, suggesting that the criminal justice system may be an important, under-utilized venue for implementing overdose prevention strategies. To better understand the feasibility and acceptability of such strategies, we evaluated the utilization of naloxone-based overdose prevention training among people who inject drugs with and without a history of incarceration. MethodsWe surveyed clients who utilize a multi-site syringe exchange program (SEP) in 2 cities in the Midwestern United States. Participants completed an 88-item, computerized survey assessing history of incarceration, consequences associated with injection, injecting practices, and uptake of harm reduction strategies. ResultsAmong 543 respondents who injected drugs in the prior 30 days, 243 (43%) reported prior incarceration. Comparing those with and without a history of incarceration, there were no significant differences with respect to age, gender, or race. Those who observed an overdose, experienced overdose, and received training to administer or have administered naloxone were more likely to report incarceration. Overall, 69% of previously incarcerated clients had been trained to administer naloxone. ConclusionPeople who inject drugs with a history of incarceration appear to have a higher risk of opioid overdose than those never incarcerated, and are more willing to utilize naloxone as an overdose prevention strategy. Naloxone training and distribution is an important component of comprehensive prevention services for persons with opioid use disorders. Expansion of services for persons leaving correctional facilities should be considered.