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2 The Scope of the Problem
Pages 9-52

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From page 9...
... GEOGRAPHY OF INFECTIOUS DISEASES RELATED TO THE OPIOID EPIDEMIC Patrick Sullivan explored the geography of infectious diseases related to the opioid epidemic, particularly HIV and HCV, providing an epidemiological perspective about how infectious diseases can serve as a sentinel system for those epidemics. He also highlighted how lessons learned 9
From page 10...
... Infectious Diseases as Sentinels for Opioid Epidemics Sullivan provided an epidemiological perspective on how infectious diseases can serve as a sentinel system for opioid epidemics. To illustrate quantitatively the relationships between infectious diseases and the opioid epidemic, he cited data estimating the efficiency of HIV and HCV transmission through needle sharing.
From page 11...
... That is, what is the likelihood that the infection will be sustained, rather than resolving spontaneously or resolving after treatment without recognition of an underlying needle-sharing event? These five dimensions vary across HIV, HCV, skin infections, and infectious endocarditis, so he comparatively assessed the relative potentials of those infectious diseases to serve as sentinel events.
From page 12...
... .3 Sullivan explained that AIDSVu allows researchers to focus specifically on people living with diagnosed HIV attributed to injection drug use. The top map in Figure 2-1 shows the results of decades of accumulation of HIV infections associated with injection drug use.
From page 13...
... . 2-1 Bottom SOURCES: As presented by Patrick Sullivan at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; AIDSVu, 2018.
From page 14...
... At an even more local level of geographic granularity, these types of maps can be useful when correlated with service data and with indicators of substance abuse. He illustrated this by presenting a map of the numbers of new HIV diagnoses in the Atlanta metropolitan statistical area -- that is, areas where HIV testing and HIV prevention services are most needed.
From page 15...
... Sullivan surmised that a substantial part of this reemergence is related to opioid epidemics. Sullivan remarked that HCV has interesting characteristics as a potential indicator for better understanding opioid epidemics, but without national surveillance, it has not been possible to estimate HCV prevalence across the United States in a systematic way.
From page 16...
... HCV = hepatitis C virus. SOURCES: As presented by Patrick Sullivan at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; CDC, 2017.
From page 17...
... yrs = years. SOURCES: As presented by Patrick Sullivan at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; CDC, 2017.
From page 18...
... SOURCES: As presented by Patrick Sullivan at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; HepVu, 2018. of the decade (HepVu, 2018)
From page 19...
... Because of intertwined issues of depression and substance use, he said, there is also concern that overdoses designated as unintentional might actually be intentional. Ideally, medical records would capture substance abuse data for people who present with infectious diseases like endocarditis, cellulitis, and abscesses, but usually they do not.
From page 20...
... SOURCES: As presented by Patrick Sullivan at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; Hedegaard et al., 2017. of agents; there has also been an increase in the representation of heroin in these drug overdose deaths.
From page 21...
... They created a base map to represent the intensity of drug overdose deaths per 100,000 overlaid with the locations of substance abuse treatment facilities that accept 4 See https://www.cdc.gov/vitalsigns/opioid-overdoses/infographic.html#graphic2 (ac cessed May 1, 2018)
From page 22...
... Discussion Carl Schmid of the AIDS Institute asked whether HBV is also increasing in many areas because of the opioid epidemic and injection drug use. Sullivan replied that as new infectious diseases emerge and are characterized descriptively as outbreaks, one of the challenges is figuring out how
From page 23...
... In the meantime, he suggested leveraging the contributions of the existing surveillance systems and indicators, upon which descriptions of outbreaks like HBV can be layered. Judith Feinberg of West Virginia University suggested that heat maps by county serve as adequately sensitive indicators to demonstrate that in the southern part of West Virginia there is almost a complete correlation for acute HCV and overdose mortality.
From page 24...
... People who were injecting drugs would use syringes and then leave them behind, where they would continue to be used by other people. As a result, Rhode Island was one of only four states at the time with more than half of AIDS cases related to injection drug use.
From page 25...
... . MODELING THE PREVENTION OF INFECTIOUS DISEASES AMONG PEOPLE WHO INJECT DRUGS In her presentation, Natasha Martin described how infectious disease epidemic modeling can be used to identify the scope of the response needed to prevent HIV and HCV infection among PWID in the United States.
From page 26...
... For example, 2017 Medicaid restrictions for HCV therapy in many states impose restrictions based on drug and alcohol use, including abstinencebased restrictions, despite clinical recommendations that recent drug use should not be a contraindication to HCV treatment. Some states also impose restrictions based on liver damage, with treatment prioritized for individuals with more advanced fibrosis.
From page 27...
... Martin explained that Perry County, Kentucky, also has a high prevalence rate of HCV among PWID, although it has a moderate but stable incidence rate of around 20 per 100 person-years. The HCV epidemic is slowly expanding among PWID, but in contrast to San Francisco, modeling predicts that scaling up to full harm reduction (syringe service programs plus medication-assisted treatment [MAT]
From page 28...
... Achieving elimination is possible, she said, but it would require a scale up of harm reduction combined with HCV treatment at rates of less than 50 per 1,000 PWID annually. Scott County, Indiana, also has a relatively high prevalence of HCV among PWID, coupled with an expanding epidemic.
From page 29...
... . pled with harm reduction scale up, treatment rates of below 75 per 1,000 PWID annually could achieve elimination in San Francisco and in Perry County (Fraser et al., 2018)
From page 30...
... Therefore, the set ting will determine how network considerations might be taken into account when planning allocation of HCV treatment. SOURCE: As presented by Natasha Martin at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018.
From page 31...
... SOURCES: As presented by Natasha Martin at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; adapted from Skarbinski et al., 2015.
From page 32...
... Exploring Challenges and Opportunities Among Incarcerated People Who Inject Drugs Martin explained that there are high burdens of PWID in prisons who experience high rates of infectious diseases; prison appears to increase their risk of transmission of these diseases. A recent systematic review and meta-analysis found that compared to nonrecent incarceration, recent incarceration significantly increases the risk of acquiring HIV by an estimated 81 percent and increases the risk of acquiring HCV by an estimated 62 percent among PWID (Stone et al., 2017)
From page 33...
... She reported that if the reforms were implemented properly -- that is, if no syringes were confiscated and OAT were provided instead of incarceration for 80 percent of PWID -- then these changes could avert 21 percent of new HIV infections among PWID in Tijuana between 2018 and 2030. Prison also provides an excellent access point to engage people both in treatment and in harm reduction, Martin said, and researchers are now looking at the community benefits of treatment and harm reduction in prisons.
From page 34...
... 34 OPIOID USE DISORDER AND INFECTIOUS DISEASE EPIDEMICS United States 14,000 12,000 Number of Infections Averted 10,000 8,000 6,000 4,000 2,000 0 1-year risk 1-year all 5-year all 10-year all General Population Prisons
From page 35...
... SOURCES: As presented by Natasha Martin at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; top figure from He et al., 2016; bottom figure adapted from Stone et al., 2017.
From page 36...
... Most models indicate that there will be no effect on the epidemic without scale up of treatment, given the extremely low treatment rates among PWID historically and in recent years. ECONOMIC IMPLICATIONS OF TREATMENT PROGRAMS Benjamin Linas provided a health-economic perspective on the implications of treatment programs, exploring strategies for setting valuedriven priorities to address the opioid epidemic and its infectious disease consequences.
From page 37...
... SOURCE: As presented by Benjamin Linas at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018.
From page 38...
... He emphasized that cost-effectiveness maximizes population-level benefits of medical therapies, and although it does not seek to minimize cost, it does require explicit decisions about opportunity costs and the bang for the buck in the current health care system, which sometimes make people uncomfortable. Finding Value in Addressing Hepatitis C Virus Summary: Health Economics of HCV HCV is the most common chronic infectious sequela of injection drug use, but despite that fact there has been robust national debate about the high cost of HCV treatment and the proper approach to HCV in PWID.
From page 39...
... Research is emerging around the cost-effectiveness of the new HCV therapies, indicating unanimously that they are robustly cost-effective in every genotype, with shorter treatment regimens, in injection drug users and other analyses (Leidner et al., 2015; Linas et al., 2015; Martin et al., 2012; Morgan et al., 2018; Rein et al., 2015; Younossi et al., 2017)
From page 40...
... HIV = human immunodeficiency virus; NSP = needle services program; OAT = opiate agonist therapy; PrEP = preexposure prophylaxis; QALY = quality adjusted life-years. SOURCES: As presented by Benjamin Linas at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; adapted from Bernard et al., 2017.
From page 41...
... SOURCES: As presented by Benjamin Linas at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; Clark et al., 2009.
From page 42...
... PERSPECTIVES OF PATIENTS AND PROVIDERS A provider's perspective on the infectious disease consequences of the opioid epidemic was shared by Seun Falade-Nwulia, who was the past medical director of the Baltimore City Health Department HIV Early Intervention Initiative program, which provides HIV and HCV care in the public health clinics. She is currently an assistant professor in the Division of Infectious Diseases of the Johns Hopkins University School of Medicine and drew on her range of experiences working on the inpatient service,
From page 43...
... Falade-Nwulia is frequently consulted on patients who inject drugs who have been readmitted to the inpatient service for these infections that have progressed despite previous discharge to a facility on an appropriate course of prolonged (e.g., 6 weeks) of intravenous antibiotics.
From page 44...
... She reiterated the need to incorporate screening for infectious diseases and more effectively deploying existing preventive tools, such as treatments to prevent transmission of HCV and HIV, linking to harm reduction through NSPs, and providing MAT. A patient's perspective was offered generously by Veda Moore, a resident of Baltimore, Maryland.
From page 45...
... After that happened, I started using drugs. It went from drinking and smoking cigarettes to popping pills.
From page 46...
... She said she would tell them not to be so judgmental. She left the hospital and went back to using drugs, but if someone had talked with her and intervened at that point, her drug use may have stopped then.
From page 47...
... SOURCE: As presented by Veda Moore at the workshop Integrating Infectious Disease Con siderations with Response to the Opioid Epidemic on March 12, 2018. Discussion Within the rubric of meeting patients where they are, regardless of the setting, Korthuis asked if all available treatments for substance use, HIV, and HCV are offered to an individual at the same time, or if they are considered in a more sequential way.
From page 48...
... Korthuis asked about the experiences in accessing care among people who need treatment for addiction, HIV, and HCV. Moore responded that addiction needs to be dealt with first for people in that situation, because patients who are using drugs often do not care about their HIV or HCV status because of their overwhelming focus on the "next fix." She reminded the group that people have a right to make bad decisions and they have to be willing to deal with the core reasons that they are using drugs in order to engage with treatment.
From page 49...
... Clinical Infectious Diseases 66(3)
From page 50...
... Clinical Infectious Diseases. https://doi.org/10.1093/ cid/ciy098 (accessed June 15, 2018)
From page 51...
... Clinical Infectious Diseases 61(2)
From page 52...
... Lancet Infectious Diseases 18(2)


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