AIDS Linked To The IntraVenous Experience Research Articles

Association of inadequate sleep with mortality among persons who inject drugs

BackgroundInadequate sleep is associated with all-cause mortality in the general population. Substance use has adverse effects on sleep, and insomnia symptoms are common among people with HIV. Therefore, persons who inject drugs may face a heightened risk of adverse outcomes from inadequate sleep. We evaluated the association of inadequate sleep with mortality among persons who inject drugs in a long-standing community cohort. MethodsParticipants were from the AIDS Linked to the IntraVenous Experience (ALIVE) study, a cohort of persons who inject drugs in Baltimore, Maryland, USA. From 2005-2020, perceived sleep adequacy and duration were assessed semiannually using survey. Mortality data were obtained through linkage to the National Death Index-Plus. Cause of death was independently characterized and validated by three physicians. Hazards of all-cause and cause-specific mortality were evaluated using Cox regression accounting for repeated measurements. ResultsA total of 2633 participants were included, with a median age at entry of 45.8years; 32.5% were female, and 75% were Black. After adjustment for demographics, mental health, and comorbidities, inadequate sleep was associated with a 32% greater hazard of all-cause mortality (hazard ratio: 1.32, 95% confidence interval: 1.12-1.55) and a 67% greater hazard of HIV/infectious disease-related deaths (hazard ratio: 1.67, 95% confidence interval: 1.15-2.42). Short (<6 hours) and long (≥8 hours) duration of sleep were both associated with higher hazard of all-cause and chronic disease-related mortality (all p < .05). ConclusionsSleep plays a critical role in longevity in persons who inject drugs. Research is needed to determine whether interventions targeting sleep improve health and longevity in persons who inject drugs.

Association of primary care engagement with initiation and continuation of medication treatment for opioid use disorder among persons with a history of injection drug use

BackgroundFor patients with opioid use disorder (OUD), primary care can serve as a pathway to medication for OUD (MOUD). No community-based studies have examined whether people with OUD engaged in primary care are more likely to a) initiate or b) continue MOUD. MethodsData were collected 2014–2020 from two subsamples of the AIDS Linked to the Intravenous Experience (ALIVE) cohort, a community-recruited cohort of people from Baltimore who have injected drugs: 1) people who reported past-six-month illicit opioid use and no MOUD (360 participants, 789 study visits), and 2) people who reported MOUD and no illicit opioid use in the past six months (561 participants, 2027 visits). Logistic regression was used to estimate associations of past six-month self-reported primary care engagement, respectively, with a) initiating MOUD, b) continuing MOUD, and c) cessation from illicit opioid use without initiating MOUD. ResultsAmong 360 persons not on MOUD treatment (28 % female, 26 % under 50, 59 % actively injecting drugs), primary care engagement was not associated with either cessation from illicit opioid use or initiating MOUD. Similarly, among persons on MOUD (40 % female, 22 % under 50, 6 % actively injecting drugs) primary care engagement was not associated with continued treatment. ConclusionsOur findings implicate missed opportunities to initiate and maintain buprenorphine treatment in primary care settings.

Baltimore oral epidemiology, disease effects, and HIV evaluation study (BEEHIVE) study protocol: a prospective cohort study

BackgroundAs antiretroviral therapy has become widely available and highly effective, HIV has evolved to a manageable, chronic disease. Despite this health advancement, people living with HIV (PLWH) are at an increased risk for age-related non-communicable diseases (NCDs) compared to HIV-uninfected individuals. Similarly, PLWH are at an increased risk for selected oral diseases. PLWH with a history of injecting drugs experience an even greater burden of disease than their counterparts. The overall objective of the Baltimore Oral Epidemiology, Disease Effects, and HIV Evaluation (BEEHIVE) study is to determine the combined effects of HIV infection and NCDs on oral health status. The specific aims of the study are to: (1) determine to what extent HIV status influences access to and utilization of oral health care services; (2) determine to what extent HIV status affects self-reported and clinical oral health status; (3) determine to what extent HIV status influences the progression of periodontitis; and (4) determine to what extent HIV status impacts the periodontitis-associated oral microbiome signature.MethodsThe BEEHIVE study uses a prospective cohort study design to collect data from participants at baseline and at a 24-month follow-up visit. Data are collected through questionnaire assessments, clinical examinations, and evaluation of oral microbiological samples to determine the drivers of oral disease among a high-risk population of PLWH with a history of injection drug use and prevalent comorbid NCDs. The established AIDS Linked to the Intravenous Experience (ALIVE) cohort serves as the source of participants for the BEEHIVE Study.DiscussionUpon completion of the BEEHIVE study, the knowledge gained will be important in informing future clinical and preventive interventions that can be implemented into medical and dental practice to ultimately help eliminate long-standing oral health inequities that PLWH experience.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use

Background: People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population. Methods: This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status. Results: 1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15–1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04–1.59) and among some subgroups. Conclusions: Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

Longitudinal patterns of use of stimulants and opioids in the AIDS linked to the IntraVenous experience cohort, 2005–2019

BackgroundOverdoses involving opioids and stimulants are on the rise, yet few studies have examined longitudinal trends in use of both substances. We sought to describe use and co-use of opioids and stimulants, 2005–2019, in the AIDS Linked to the Intravenous Experience (ALIVE) cohort – a community-based cohort of people with a history of injection drug use living in or near Baltimore, MD. MethodsWe included 2083 ALIVE participants, who had at least two visits during the study period. Our outcome was based on self-reported use of opioids and stimulants in the prior 6 months. We estimated prevalence of 4 categories of use (neither stimulants nor opioids, only stimulants, only opioids, stimulants and opioids), using a non-parametric multi-state model, accounting for the competing event of death and weighting for informative loss to follow-up. All analyses were stratified by enrollment cohort, with the main analysis including participants who enrolled prior to 2015 and a sub-analysis including participants who enrolled 2015–2018. ResultsIn the main analysis, prevalence of using stimulants and opioids decreased from 38 % in 2005 to 12 % 2013 but stabilized from 2014 onwards (13–19 %). The prevalence of using only stimulants (7–11 %) and only opioids (5–10 %) was stable across time. Participants who reported using both were more likely to report homelessness, depression, and other substance use (e.g., marijuana and heavy alcohol use) than participants in the other use categories. On average, 65 % of visits with use of both were followed by a subsequent visit with use of both; of participants transitioning out of using both, 13% transitioned to using neither. ConclusionsWhile use of stimulants and opioids declined in the cohort through 2013, a meaningful proportion of participants persistently used both. More research is needed to understand and develop strategies to mitigate harms associated with persistent use of both stimulants and opioids.

Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in Baltimore, Maryland

BackgroundSARS-CoV-2 serosurveys can help characterize disparities in SARS-CoV-2 infection and identify gaps in population immunity. Data on SARS-CoV-2 seroprevalence among people who inject drugs (PWID) are limited. MethodsWe conducted a cross-sectional study between December 2020 and July 2022 among 561 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study—a community-based cohort of current and former PWID in Baltimore, Maryland. Serum samples were assayed for infection-induced anti-nucleocapsid (anti-N) and infection and/or vaccination-induced anti-spike-1 (anti-S) SARS-CoV-2 IgG. We estimated adjusted prevalence ratios (aPR) via modified Poisson regression models. ResultsThe median age was 59 years, 35% were female, 84% were non-Hispanic Black, and 16% reported recent injection drug use. Anti-N antibody prevalence was 26% and anti-S antibody prevalence was 63%. Anti-N and anti-S antibody prevalence increased over time. Being employed (aPR=1.53 [95%CI=1.11–2.11]) was associated with higher anti-N prevalence, while a cancer history (aPR=0.40 [95%CI=0.17–0.90]) was associated with lower anti-N prevalence. HIV infection was associated with higher anti-S prevalence (aPR=1.13 [95%CI=1.02–1.27]), while younger age and experiencing homelessness (aPR=0.78 [95%CI=0.60–0.99]) were factors associated with lower anti-S prevalence. Substance use-related behaviors were not significantly associated with anti-N or anti-S prevalence. ConclusionsSARS-CoV-2 seroprevalence increased over time among current and former PWID, suggesting cumulative increases in the incidence of SARS-CoV-2 infection and vaccination; however, there were disparities in infection-induced seroprevalence and infection and/or vaccine-induced seroprevalence within this study sample. Dedicated prevention and vaccination programs are needed to prevent disparities in infection and gaps in population immunity among PWID during emerging epidemics.

Context and correlates of providing assistance with someone’s first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD

BackgroundThe social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual’s first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID. MethodsParticipants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019–2020 about assisting with another person’s first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics. ResultsAt baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1–4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4–4.6]), syringe sharing (2.2 [1.2–3.9]), and injecting ≥3 times per day (2.0 [1.2–3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person’s lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury. ConclusionPWID with a history of assisting with another person’s first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD.

We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.

Temporal association of pre-pandemic perceived social support with psychological resilience and mental well-being during the COVID-19 pandemic among people with a history of injection drug use

BackgroundThere are limited data on whether modifiable social factors foster psychological resilience and mental well-being among people who use drugs following Big Events. We examined the temporal association of pre-pandemic perceived social support with psychological resilience and negative mental health symptoms during the COVID-19 pandemic among people with a history of injection drug use. MethodsBetween June and September 2020, we conducted a telephone survey among 545 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study: a community-based cohort of adults with a history of injection drug use. Leveraging data from study visits in 2018-early 2020, associations of pre-pandemic perceived social support with psychological resilience scores (range=1–5) and the probability of negative mental health symptoms during the pandemic were assessed using multivariable linear and modified Poisson regression models, respectively. ResultsParticipants’ median age was 58 years, 38.2% were female, 83.3% identified as Black, and 30.3% were living with HIV. During the pandemic, 14.5% had low (<3) resilience scores, 36.1% experienced anxiety, and 35.8% reported increased loneliness. Compared to participants in the lowest tertile of pre-pandemic social support, participants in the highest tertile had higher mean resilience scores (β = 0.27 [95% CI = 0.12, 0.43]), a lower probability of anxiety (prevalence ratio [PR] = 0.71 [95% CI = 0.52, 0.96]), and a lower probability of increased loneliness (PR = 0.62 [95% CI = 0.45, 0.84]). ConclusionsPre-pandemic perceived social support was associated with greater psychological resilience and generally better mental well-being during the pandemic. Interventions that improve social support may foster psychological resilience and protect the mental well-being of people who use drugs, especially during periods of social disruption.

Mortality by cause of death during year 1 of the COVID-19 pandemic in a cohort of older adults from Baltimore Maryland who have injected drugs.

BackgroundIn 2020, the first year of the COVID-19 pandemic, overdose deaths increased. However, no studies have characterized changes in mortality during the pandemic in a well-characterized cohort of people who use drugs in active follow-up at the time of pandemic onset.DesignWe compared all-cause and cause-specific mortality in the first year of the pandemic (Mar–Dec 2020) to the five years preceding (Jan 2015–Feb 2020), among participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study: a community-recruited cohort of adults from Baltimore who have injected drugs. 3510 participants contributed 17,498 person-years [py] of follow-up time. Cause and dates of death were ascertained through the National Death Index. Comparisons were made for the full cohort and within subgroups with potentially differential levels of vulnerability.ResultsAll-cause mortality in 2020 was 39.6 per 1000 py, as compared to 37.2 per 1000 py pre- pandemic (Adjusted Incidence Rate Ratio = 1.09, 95%: confidence interval: 0.84–1.41). Increases were mostly attributable to chronic disease deaths; injury/poisoning deaths did not increase. No pre-post differences were statistically significant.ConclusionIn this exploratory analysis of an older cohort of urban-dwelling adults who have injected drugs, mortality changes during the first year of the pandemic differed from national trends and varied across potentially vulnerable subgroups. More research is needed to understand determinants of increased risk of mortality during the pandemic among subgroups of people who use drugs.

Impact of Hepatitis C Treatment Uptake on Cirrhosis and Mortality in Persons Who Inject Drugs : A Longitudinal, Community-Based Cohort Study.

Hepatitis C virus (HCV) infection can be cured, and the United States has joined the World Health Organization in calling for HCV elimination by 2030. However, historically low uptake of HCV treatment among people who inject drugs (PWID) threatens HCV elimination and exacerbates social and racial health disparities. To assess whether all-oral HCV treatments were accessed by PWID and reduced liver disease burden and mortality. Community-based, longitudinal cohort study of persons with a history of injection drug use. Baltimore, Maryland. 1323 participants enrolled in the ALIVE (AIDS Linked to the IntraVenous Experience) study from 2006 to 2019 and chronically infected with HCV. Liver stiffness measures (LSMs) by transient elastography, HCV RNA, and mortality from the National Death Index. Among 1323 persons with evidence of chronic HCV infection at baseline, the median age was 49 years. Most were Black (82%), male (71%), and HIV-negative (66%). The proportion in whom HCV RNA was detected decreased from 100% (by definition) in 2006 to 48% in 2019. Across 10350 valid LSMs, cirrhosis was detected in 15% of participants in 2006, 19% in 2015, and 8% in 2019. Undetectable HCV RNA was significantly associated with reduced odds of cirrhosis (adjusted odds ratio, 0.28 [95% CI, 0.17 to 0.45]) and reduced all-cause mortality risk (adjusted hazard ratio, 0.54 [CI, 0.38 to 0.77]). Noninvasive markers of liver fibrosis have not been validated in persons with sustained virologic response. Many community-based PWID in Baltimore are receiving HCV treatment, which is associated with sharp decreases in liver disease and mortality. Additional efforts will be needed to reduce residual barriers to treatment and to eliminate HCV as a public health threat for PWID. National Institutes of Health.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BackgroundAging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID. MethodsWe conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization. ResultsOf 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder. DiscussionHolistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Trends in fatal and nonfatal overdose by race among people who inject drugs in Baltimore, Maryland from 1998 to 2019

ObjectiveThe objective of this study was to examine trends in fatal and nonfatal overdose in a community-based sample of current and former people who inject drugs (PWID). MethodsData from 4826 current and former PWID from the AIDS Linked to the IntraVenous Experience (ALIVE) observational cohort study in Baltimore, Maryland, were used to characterize fatal and nonfatal overdose rates from 1998 to 2019. Poisson regression was used to examine factors associated with nonfatal overdose and differences by race among 1052 PWID between 2014 and 2019. ResultsFatal overdose rates reached a high of 13 per 1000 person-years in 2018. Among 1052 current and former PWID, of whom 75% were Black and one-third were female, the nonfatal overdose rate of 529 per 1000 person-years in 2019 was 8 times higher than 2014 (incidence rate ratio [IRR]=7.76, 95% CI: 3.35, 18.0). The annual adjusted increase in nonfatal overdose rate was 53% among Black PWID (IRR=1.53, 95% CI: 1.34, 1.75), compared to 14% among White PWID (IRR=1.14, 95% CI: 0.88, 1.46). Urban residence, opioid use, depressive symptoms, and hepatitis C infection were positively associated with nonfatal overdose among Black PWID. Recent injection drug use and tranquilizer use was associated with increased overdose among Black and White PWID. ConclusionsRates of fatal and nonfatal overdose were high and increased from 2014 to 2019 among current and former PWID, with the most dramatic increases in nonfatal overdose observed among Black PWID. These findings highlight the urgent need for additional resources to reduce the differential harms associated with opioids by race.

Mortality among people who inject drugs: a prospective cohort followed over three decades in Baltimore, MD, USA.

During the past decades, people who inject drugs (PWID) have been impacted by the development of combination antiretroviral therapy (cART) to combat HIV/AIDS, the prescription opioid crisis and increased use of lethal synthetic opioids. We measured how these dynamics have impacted mortality among PWID in an urban US city. Prospective cohort study using data from the AIDS Linked to the Intravenous Experience (ALIVE). Baltimore, MD, USA from 1988 to 2018. A total of 5506 adult PWIDs (median age at baseline 37 years). Mortality was identified by linkage to National Death Index-Plus (NDI-Plus) and categorized into HIV/infectious disease (HIV/ID) deaths, overdose and violence-related (drug-related) deaths and chronic disease deaths. Person-time at risk accrued from baseline and ended at the earliest of death or study period. All-cause and cause-specific mortality were calculated annually. The Fine & Gray method was used to estimate the subdistribution hazards of cause-specific deaths accounting for competing risks. Among 5506 participants with 84 226 person-years of follow-up, 43.9% were deceased by 2018. Among all deaths, 30.5% were HIV/ID deaths, 24.4% drug-related deaths and 33.3% chronic disease deaths. Age-standardized all-cause mortality increased from 23 to 45 per 1000 person-years from 1988 to 1996, declined from 1996 to 2014, then trended upward to 2018. HIV/ID deaths peaked in 1996 coincident with the availability of cART, then continuously declined. Chronic disease deaths increased continuously as the cohort aged. Drug-related deaths declined until 2011, but increased more than fourfold by 2018. HIV/HCV infection and active injecting were independently associated with HIV/ID and drug-related deaths. Female and black participants had a higher risk of dying from HIV/ID deaths and a lower risk of dying from drug-related deaths than male and non-black participants. Deaths in Baltimore, MD, USA attributable to HIV/ID appear to have declined following the widespread use of combination antiretroviral therapy. Increases in the rates of drug-related deaths in Baltimore were observed prior to and continue in conjunction with national mortality rates associated with the opiate crisis.

Methadone Maintenance Treatment, Sex Hormones and Low Bone Density in a Population of Injection Drug Users

Background: Methadone maintenance treatment (MMT) is associated with low bone mineral density (BMD) in those treated for opioid addiction. However, it is unclear whether observed adverse effects on the skeleton are related to a direct effect of opioids on bone metabolism or mediated by other mechanisms including MMT-induced gonadal dysfunction. We hypothesized that MMT is associated with low BMD in persons with a history of injection drug use (PWID) and that this effect is explained by differences in sex hormones. Methods: We recruited 280 participants from the AIDS Linked to the Intravenous Experience (ALIVE) study, a long-standing cohort of PWID. All participants had been exposed to hepatitis C virus (HCV antibody positive). In addition to a morning assessment of free testosterone (FT) and estradiol (E2), all participants underwent dual-energy x-ray absorptiometry (DXA) of the lumbar spine (LS) and hip (total hip (TH) and femoral neck (FN)). Multivariable linear regression was used to assess the relationship between MMT and T-score with and without inclusion of E2/FT concentrations. Models were stratified by sex and adjusted for age, BMI, HCV infection, HIV, current alcohol use, current smoking, vitamin D3 level, and current heroin use. Results: All participants were African American and 37% female. The median (Q1, Q3) age was 57 years (51, 61), median (Q1, Q3) BMI was 26 kg/m2 (22, 30) and 107 (38%) were receiving MMT. FT and E2 were significantly lower in men receiving MMT vs not (p < 0.01 for both). In women, there were no differences in sex hormones based on MMT use. The prevalence of low BMD (defined as LS, TH, or FN T-score ≤ -1) was 25% (23% in men and 29% in women; p = 0.3); 12 (4.3%, 2 men and 8 women; p = 0.09) had osteoporosis (T-score ≤ -2.5). In men, MMT was associated with -0.7 lower LS-T score (95% CI [-1.3, -0.1], p=0.046) in adjusted models compared to those not receiving MMT. The magnitude of this association was reduced after adjusting for E2 and FT (-0.2, 95% CI [-0.8, 0.5], p=0.665)). In women, MMT was not associated with LS-T score (MD -0.3, 95% CI [-1.3, 0.4], p=0.631). There were no associations between MMT and TH or FN BMD in either men or women. Conclusion: In this study, MMT was associated with lower lumbar spine BMD in men with a history of IDU, which was potentially mediated by the effect of MMT on sex hormones. More rigorous screening for co-morbidities including hypogonadism and low BMD in men receiving MMT may be warranted.

665 Insufficient sleep and mortality among persons who inject drugs (PWID)

Abstract Introduction Insufficient sleep is associated with all-cause mortality in the general population. Illicit drugs have pronounced effects upon sleep, and insomnia symptoms are common among people with HIV (PWH), suggesting persons who inject drugs (PWID) with HIV may be at higher risk of adverse outcomes from insufficient sleep. Methods Participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, a cohort of PWID with or without HIV, completed the Sleep Adequacy subscale of the Medical Outcomes Study (MOS) semi-annually from 2005-present. Two questions queried participants about the frequency over the past four-weeks of: 1. getting sufficient sleep to feel rested on awakening; 2. obtaining needed amount of sleep. Six-Item responses ranged from “all of the time” to “none of the time”. Participants with mean subscale scores below the sample median were considered to have insufficient sleep. Mortality data were obtained through the National Death Index through 2018. Hazards of all-cause and cause-specific mortality were evaluated using Cox-regressions accounting for repeated measurements of insufficient sleep, respectively. Models were adjusted for sociodemographics, HIV and HCV infection, severe depressive symptoms (Center for Epidemiological Studies Depression [CESD]≥23), number of comorbidities (0, 1, ≥2), active injection drug use, current tobacco and alcohol use. Results Of 2612 participants (33% HIV+), mean age at baseline was 45.8 years, 32.4% were female, 75% Black, 45% had ≥high school education, and 33% had an annual income &amp;gt;$5,000. At baseline, the majority were current smokers (84%), alcohol drinkers (59%), or actively injecting drugs (56%), while 25% had severe depressive symptoms and 21% had ≥2 comorbidities. After adjustment for covariates, insufficient sleep was associated with a 37% increased hazard of all-cause mortality (HR: 1.37, 95% confidence interval [CI]: 1.13–1.65). Insufficient sleep was associated with a 93% increased hazard of death from HIV or infectious disease-related deaths (HR: 1.93, 95% CI: 1.26–2.97). Conclusion Insufficient sleep was independently associated with all-cause mortality and specifically with death from HIV or infectious diseases-related causes among PWID. Interventions consider targeting sleep behaviors among PWID hold promise for improving health and longevity in this population. Support (if any) National Institutes of Health grants: U01-DA-036297; R01-DA-047064; R01-HL-90483; K24-AI-118591; T32-DA007292; R01-DA039408.

The health and social consequences during the initial period of the COVID-19 pandemic among current and former people who inject drugs: A rapid phone survey in Baltimore, Maryland

BackgroundThere is limited data on the health and social consequences of the COVID-19 pandemic among people who inject drugs (PWID). MethodsWe conducted a rapid telephone survey from April-June 2020 among participants of the community-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort study in Baltimore, Maryland. This interviewer-administered survey collected information on COVID-19 knowledge, symptoms, testing, diagnosis, and prevention behaviors, recent substance use, housing conditions, interruptions to healthcare, access to harm reduction and drug treatment, mental health, and social support. ResultsOf 443 current and former PWID who participated in the survey, 36 % were female, 85 % were Black, 33 % were living with HIV and 50 % reported any substance use in the prior six months. COVID-19 awareness was high, but knowledge of symptoms and routes of transmission were lower. PWID reporting recent substance use were less likely to always socially distance (63 % vs. 74 % among those without recent use, p = 0.02), and Black PWID were more likely than non-Black to socially distance (73 % vs. 48 %, p < 0.0001) and use when alone (68 % vs.35 %, p < 0.01). Only 6% reported difficulty accessing healthcare, yet only 48 % of those on opioid-agonist treatment had a four-week supply available. While 34 % reported increased depressive symptoms, participants reported high levels of social support. ConclusionsThis rapid assessment highlighted that PWID currently using drugs may be less able to practice social distancing and increased SARS-CoV-2 transmission may occur. Ongoing monitoring of substance use and mental health, as well as overdose prevention is necessary as the pandemic and public health responses continue.

Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era.

Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era. We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake. Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]). Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.

Fatal overdose prevention and experience with naloxone: A cross-sectional study from a community-based cohort of people who inject drugs in Baltimore, Maryland.

IntroductionOverdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID.MethodsDuring 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population.ResultsMedian age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone.ConclusionFurther work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.

Characterizing latent classes of social support among persons who inject drugs

BackgroundSocial network members influence risk and health behaviors, yet little is known about the support that persons who inject drugs (PWID) receive from their closest ties. Methods970 participants from the AIDS Linked to the IntraVenous Experience (ALIVE) study completed a social network survey between April 2016 and June 2017 about their five closest ties. Our analysis: 1) identified latent classes of support received by participants; 2) determined whether class membership differed by current (≤12 months) vs. former (>12 months) injection drug use; 3) compared classes of support by individual and network characteristics. Results970 participants listed 3,388 network members. We identified three support classes: (1) Moderate (n = 249): probabilities of support <0.40; (2) High (n = 366): probabilities of support 0.58-0.82; (3) Very high (n = 355): probabilities of support 0.91-0.99. In adjusted analysis compared to moderate support, the odds of high and very high support increased as the mean age of network members increased (Adjusted Odds Ratio [AOR]:1.03; 95 % CI: 1.01, 1.05) and as the number of network members with whom they interacted daily increased (AOR-high: 1.33; 95 % CI:1.14, 1.56 and AOR-very high: 1.54; 95 % CI: 1.30, 1.83). While current injection drug use was associated with lower unadjusted odds of high and very high support, the associations were not statistically significant in adjusted analysis. ConclusionsSupport was higher among networks of older ties and more frequent interaction, but differences did not appear to be driven by injection drug use status. Findings point to the importance of the closest social ties.