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Blood-Borne & Sexually Transmitted Infections among Substance Use Disorder Patients in a Low-Barrier Medication Clinic

This study examines the proportion of blood-borne and sexually transmitted infections among patients with substance use disorder in a low-barrier medication clinic, and evaluates the success of treatment and linkage to care. Viral infections include HIV, Hepatitis A, B, and C, while bacterial infections include Syphilis, Gonorrhea, and Chlamydia.

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Blood-Borne & Sexually Transmitted Infections among Substance Use Disorder Patients in a Low-Barrier Medication Clinic

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  1. Sexually Transmitted and Blood-Borne Infections among Patients Presenting to a Low-Barrier Substance Use Disorder Medication Clinic Leah Harvey, MD, MPH; Jessica Taylor, MD; Sabrina Assoumou, MD, MPH; Jessica Kehoe, RN; Ryan Perera; Elissa Schechter-Perkins, MD, MPH; Edward Bernstein, MD; Alexander Walley, MD, MSc

  2. Disclosures • No financial or commercial interests

  3. Age-Adjusted Opioid-related Death Rate by Year

  4. Blood-borne Infections Associated with SUD in Massachusetts FIGURE 1. Acute hepatitis C virus infection incidence rate ratios* — United States,† 2015 HIV Incidence in Massachusetts, 2005 - 2017 Source: MMWR

  5. Background • Low-Barrier to Access Programs (LBAP) rapidly link people with substance use disorders (SUD) to addiction treatment, including medication • However, the role of LBAP in addressing other aspects of SUD, including infectious complications, remains uncertain

  6. Objective • To determine the proportion of blood-borne and sexually transmitted infections among patients with SUD presenting to an LBAP • To evaluate the proportion of individuals successfully treated and/or linked to care, defined as attendance of a referral appointment for infection treatment • Viral: • HIV • Hepatitis A • Hepatitis B • Hepatitis C • Bacterial: • Syphilis • Gonorrhea • Chlamydia

  7. Boston Medical Center • Largest safety net hospital in New England • >50% patients considered underserved • >32% of patients do not speak English as a primary language • Level 1 trauma center, largest and busiest in New England • Non profit, 567 bed academic medical center Photo Credit: Alex McLean, Boston University

  8. SETTING: Faster Paths to Treatment • Launched in August 2016 at Boston Medical Center • Funded through Massachusetts DPH Bureau of Substance Addiction Services’ Opioid Urgent Care Center Grant • Multidisciplinary • Rapid access to Medication for Addiction Treatment (MAT) • Referral for detox, residential recovery programs • Linkage to OBAT, primary care, behavioral health

  9. Patient Referral Source • ED • Addiction Consult Service • Word of Mouth • Recovery Programs • Primary Care Co-located with phlebotomy, pharmacy, ED RN Intake Visit • UDS • Screening labs MD Intake Visit Faster Paths Intake Process Transition to Long Term Care • OBAT • MMTP • Residential Treatment

  10. Methods • A retrospective chart review was performed of patients presenting to the LBAP for intake between January 1st – September 30th, 2017 • Data gathered via manual chart extraction • Total of 421 intake visits during study period • 17 patients had multiple intake visits during study period • 11 patients were screened for detox only • Total of 393 unique patients

  11. Results

  12. Demographics and Social Determinants of Health • Total N of 393 unique patients • Median age 38 (Range 20-69) • 29% Female • 16% Hispanic • 49% Housing Insecurity

  13. Zip Code of Last Residence

  14. Results • Of 393 patients who completed intake, 258 (66%) reported injection drug use

  15. Infections Newly Identified

  16. HIV 393 Patient Intakes 24% (97/393) Patients Not Screened 76% (299/393) Patients Screened 40% (39/97) with negative HIV Ag/Ab testing on file 50% (49/97) no prior testing on file 2.3% (9/393) with known HIV infection 0.3% (1/299) HIV Ag/Ab positive known infection 99% (297/299) HIV Ag/Ab negative 0.3% (1/299) HIV Ag/Ab positive new diagnosis 41% (16/39) negative HIV Ag/Ab within 3 months of intake Referred for treatment and did not attend appointment. Linkage to care efforts ongoing 59% (23/39) with older negative testing on file

  17. Hepatitis C 393 Patient Intakes 77% (303/393) Screened at Intake 23% (93/393) Not Screened 12% (11/93) No testing on file 57% (172/303) HCV Ab reactive 43% (131/303) HCV Ab non-reactive 46% (43/93) Self-Reported HCV +, no test on file 42% (39/93) Recent test for HCV on file 41% (16/39) HCV Ab - 39% 68/172 Newly HCV Ab + 60% (104/172) Known HCV Ab + 59% (23/39) HCV Ab + 31% (21/68) RNA not detected 69% (47/68) HCV RNA detected 32% (15/47) attended referral appointment

  18. HCV Genotypes

  19. 393 Patient Intakes Hepatitis B 72% (285/393) Screened at Intake 28% (111/393) Not Screened 14% (15/111) recently tested 43% (122/285) S Ag + Immune from Vaccination 21% (59/285) C Ab+, Cleared Infection 1% (4/285) S Ag + 2 known chronic infection 1 new chronic HBV infection 1 new acute HBV infection 1 referred to OSH for treatment 75% (3/4) attended referral appointment

  20. 393 Patient Intakes Hepatitis A 65% (255/393) Screened at Intake 35% (140/393) Not Screened 81% (114/140) No prior testing on file 17% (24/140) Prior testing available 56% (143/255) IgG positive 44% (112/255) IgG negative 29% (7/24) Prior IgG negative 71% (17/24) Prior IgG positive

  21. Syphilis 393 Patient Intakes 72% (284/393) Patients Screened 1.8% (5/284) RPR Positive 40% (2/5) TPPA negative 60% (3/5) TPPA Positive 1 referred for treatment, did not attend appointment. Linkage to care efforts ongoing 66% (2/3) treated

  22. Gonorrhea and Chlamydia 393 Patient Intakes 63% (248/393) Patients Screened 2% (4/248) Gonorrhea + 1% (3/248) Chlamydia + 4 (100%) Treated 3 (100%) Treated

  23. Summary

  24. Limitations • Limited Generalizability • Single center • BMC Infrastructure • MassHealth coverage • Retrospective Chart Review • Self-Reported data, likely under-reporting

  25. Conclusions • LBAP patients have high rates of both sexually transmitted and blood-borne infections • Results support the inclusion of comprehensive infection screening and linkage-to-care algorithms in the LBAP setting • LBAP offer new opportunities to deploy prevention services to high risk people with SUD: • Deliver HAV and HBV vaccination • Offer HCV Treatment • Expand STI screening • Provide HIV pre-exposure prophylaxis (PrEP)

  26. Jessica Taylor, MD • Alexander Walley, MD, MSc • Sabrina Assoumou, MD, MPH • Ryan Perera • Jessica Kehoe, RN • Elissa Schechter-Perkins, MD, MPH • Edward Bernstein, MD • Faster Paths staff Thank You!

  27. Centers for Disease Control. Annual Surveillance Report of Drug-Related Risks and Outcomes, United States, 2017. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf (Accessed 20 August 2018). • Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences. Hepatitis C Virus Infection Surveillance Report, 2007 - 2015. http://www.mass.gov/eohhs/gov/departments/dph/programs/id . Published January 2017. (Accessed 20 August 2018). • Massachusetts Dept of Public Health, Office of HIV/AIDS. Massachusetts Integrated HIV/AIDS Prevention and Care Plan, 2017-2021. Available at: http://www.mass.gov/eohhs/docs/dph/aids/mass-hiv-aids-plan.pdf (Accessed 20 August 2018). • Campbell CA, Canary L, Smith N, Teshale E, Ryerson AB, Ward JW. State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2017;66:465–469. DOI: http://dx.doi.org/10.15585/mmwr.mm6618a2. (Accessed 19 September 2018). • Vance A and Schuster L. Data Brief: An Assessment of Opioid-related Deaths in Massachusetts. Boston Indicators. http://www.bostonindicators.org/-/media/indicators/boston-indicators-reports/report-files/opioids-2018.pdf?la=en&hash=82606AB8DC4B6AC57B5E462A43E008B63EDBF903 (Accessed 31 October 2018). References

  28. Extra Slides

  29. HCV in MA Source: Massachusetts DPH

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