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Background Xylazine is a dangerous veterinary sedative found mainly in illicit fentanyl in the Northeast and Midwest. Its role in the Deep South overdose crisis is not well-characterized. Methods We conducted a retrospective review of autopsy data in Jefferson County, Alabama to identify trends in xylazine prevalence among people who fatally overdosed from June 2019 through June 2023. Results 165 decedents met inclusion criteria. While the first identified xylazine-associated overdose was in June 2019, xylazine has become consistently prevalent since January 2021. All cases of xylazine-associated fatal overdoses were accompanied by fentanyl, and most (75.4%) involved poly-drug stimulant use. The average age was 42.2, and most decedents were white (58.8%) and male (68.5%). Overall, 18.2% of people were unhoused at the time of death. Discussion Xylazine is prevalent in the Deep South. Efforts to promote harm reduction, publicly viewable drug supply trends, and legalization of drug checking and syringe service programs should be prioritized.

A wealth of research demonstrates that harm reduction interventions for substance use (SU) save lives and reduce risk for serious infectious diseases such as HIV, hepatitis C, and other SU-related health conditions. The U.S. has adopted several harm reduction interventions at federal and state levels to combat SU-related harm. While several policy changes on the federal and state levels decriminalized interventions and further support their use, other policies limit the reach of these interventions by delaying or restricting care, leaving access to life-saving interventions inconsistent across the U.S. Federal and state policies in the U.S. that restrict access to medications for opioid use disorder (MOUD), criminalize possession of drug paraphernalia, prevent syringe service programs and overdose prevention centers from operating, and limit prescribing of pre-exposure prophylaxis (PrEP) pose significant barriers to harm reduction access and implementation. This paper aims to bridge publications and reports on current state and federal harm reduction intervention policies and discuss policy recommendations. Federally, the DEA and SAMHSA should expand certification for methadone dispensing to settings beyond dedicated opioid treatment programs and non-OTP prescribers. Congress can decriminalize items currently categorized as paraphernalia, permit purchasing of syringes and all drug checking equipment using federal funds, amend the Controlled Substances Act to allow for expansion of overdose prevention centers, protect Medicaid coverage of PrEP, and expand Medicaid to cover residential SU treatment. At the state level, states can reduce regulations for prescribing MOUD and PrEP, decriminalize drug paraphernalia, codify Good Samaritan laws, and remove restrictions for syringe service program and overdose prevention center implementation. Lastly, states should expand Medicaid to allow broader access to treatment for SU and oppose Medicaid lock-outs based on current SU. These changes are needed as overdose deaths and serious infectious disease rates from SU continue to climb and impact American lives.

Background Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions. Methods We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site ( N  = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N  = 18) completed surveys on the acceptability and accessibility of technology for healthcare. Results Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients’ technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth. Conclusion This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias.

High sexually transmitted infection (STI) rates in the South, especially among young black men who have sex with men (YB MSM), make STI testing imperative for public health. To identify STI testing preferences in this population to improve testing delivery and utilization. YB MSM ages 16-35 in Birmingham, Alabama participated in focus groups (FG). A trained qualitative researcher coded transcripts after each FG and added questions to explore emerging themes. Between September 2017 and January 2018, 36 YB MSM participated in 5 focus groups. Median age was 25.5 (Interquartile range 22-30). Participants preferred STI testing at doctors' offices conducted by physicians but they also preferred having options related to testing locations, frequency, and timing to address diverse needs. Participants did not prefer testing by non-physician staff or home self-testing. A variety of options, including varied locations, personnel, and methods (self-collected and provider collected) are needed to make patient-preferred STI testing a reality among YB MSM in the Deep South. Further, the desire to be tested by a trusted physician highlights the need for access to primary care providers. Results suggest that newer home-based tests and self-collected tests are less preferable to YB MSM in the South, which deserves further study as these tests are rapidly integrated into clinical care.

Background Hospitalization is a “reachable moment” for people who inject drugs (PWID), but preventive care including HIV testing, prevention and treatment is rarely offered within inpatient settings. Methods We conducted a multisite, retrospective cohort study of patients with opioid use disorder with infectious complications of injection drug use hospitalized between 1/1/2018–12/31/2018. We evaluated HIV care continuum outcomes using descriptive statistics and hypothesis tests for intergroup differences. Results 322 patients were included. Of 300 patients without known HIV, only 2 had a documented discussion of PrEP, while only 1 was prescribed PrEP on discharge. Among the 22 people with HIV (PWH), only 13 (59%) had a viral load collected during admission of whom all were viremic and 10 (45%) were successfully linked to care post-discharge. Rates of readmission, Medicaid or uninsured status, and unstable housing were high in both groups. Discussion We observed poor provision of HIV testing, PrEP and other HIV services for hospitalized PWID across multiple U.S. medical centers. Future initiatives should focus on providing this group with comprehensive HIV testing and treatment services through a status neutral approach.

Background The semantics of entities extracted from a clinical text can be dramatically altered by modifiers, including entity negation, uncertainty, conditionality, severity, and subject. Existing models for determining modifiers of clinical entities involve regular expression or features weights that are trained independently for each modifier. Methods We develop and evaluate a multi-task transformer architecture design where modifiers are learned and predicted jointly using the publicly available SemEval 2015 Task 14 corpus and a new Opioid Use Disorder (OUD) data set that contains modifiers shared with SemEval as well as novel modifiers specific for OUD. We evaluate the effectiveness of our multi-task learning approach versus previously published systems and assess the feasibility of transfer learning for clinical entity modifiers when only a portion of clinical modifiers are shared. Results Our approach achieved state-of-the-art results on the ShARe corpus from SemEval 2015 Task 14, showing an increase of 1.1% on weighted accuracy, 1.7% on unweighted accuracy, and 10% on micro F1 scores. Conclusions We show that learned weights from our shared model can be effectively transferred to a new partially matched data set, validating the use of transfer learning for clinical text modifiers.

The opioid epidemic continues to be a major public health issue that includes millions of people who inject drugs (PWID). PWID have increased incidence of serious infections, including HIV as well as metabolic and inflammatory sequelae. We sought to discern the extent of systemic alterations in humoral immunity associated with injection drug use, including alterations in the plasma proteome and its regulation of B cell responsiveness. Comprehensive plasma proteomics analysis of HIV negative/hepatitis C negative individuals with a history of recent injection heroin use was performed using mass spectrometry and ELISA. The effects of plasma from PWID and healthy controls on the in vitro proliferation and transcriptional profile of B cell responses to stimulation were determined by flow cytometry and RNA-Seq. The plasma proteome of PWID was distinct from healthy control individuals, with numerous immune-related analytes significantly altered in PWID, including complement (C3, C5, C9), immunoglobulin (IgD, IgM, kappa light chain), and other inflammatory mediators (CXCL4, LPS binding protein, C-reactive protein). The plasma of PWID suppressed the in vitro proliferation of B cells. Transcriptome analysis indicated that PWID plasma treatment increased B cell receptor and CD40 signaling and shifted B cell differentiation from plasma cell-like toward germinal center B cell-like transcriptional profiles. These results indicate that the systemic inflammatory milieu is substantially altered in PWID and may impact their B cell responses.

Background Mental health (MH) comorbidities reduce retention in care for persons living with HIV (PLWH) and are associated with poor health outcomes. Optimizing retention in primary care is vital, as poor retention is associated with delayed receipt of antiretroviral (ARV) therapy, ARV non-adherence, and poor health outcomes, including failure to suppress viral load, decreased CD4 counts, and clinically significant ARV drug resistance. We hypothesized that MH service utilization would be associated with improved retention in care for patients with HIV and MH comorbidities. Methods This is a retrospective analysis of PLWH initiating outpatient HIV health care at a university-affiliated HIV clinic between January 2007 and December 2013. We examined the association between MH service utilization and retention in care, the outcome of interest, using univariate and multivariable logistic regression. Results Overall, 627 (84.4%) out of 743 patients were retained in care using the Health Resources & Services Administration HIV/AIDS Bureau (HRSA/HAB) metric. A multivariable model adjusted for several sociodemographic factors, MH comorbidities, and MH service utilization. The results suggest that lack of health insurance (public ORadj = 0.3, p < 0.01; no insurance ORadj = 0.4, p < 0.01) and ≥ 3 MH comorbidities (ORadj = 0.3, P = 0.01) were associated with decreased retention in care. Conversely, older age (> 45 years, ORadj. = 1.6, p = 0.14) and ≥ 3 MH service utilization visits (ORadj. = 6.8, p < 0.01) were associated with increased retention in care. Conclusions Even in the absence of documented MH comorbidities, improved retention in care was observed with increasing MH service utilization. In order to achieve the US-based National HIV/AIDS Strategy goal of 90% retention in care for PLWH, MH service utilization should be considered along with other evidence-based interventions to improve retention for PLWH newly engaged in care.

Background: People who inject drugs (PWID) are at risk for severe bacterial and fungal infections including skin and soft tissue infections, endocarditis, and osteomyelitis. PWID have high rates of self-directed discharge and are often not offered outpatient antimicrobial therapies, despite studies showing their efficacy and safety in PWID. This study fills a gap in knowledge of patient and community partner perspectives on treatment and discharge decision making for injection drug use (IDU)-associated infections. Methods: We conducted semi-structured interviews with patients (n = 10) hospitalized with IDU-associated infections and community partners (n = 6) in the Portland, Maine region. Community partners include peer support workers at syringe services programs (SSPs) and outreach specialists working with PWID. We transcribed and thematically analyzed interviews to explore perspectives on three domains: perspectives on long-term hospitalization, outpatient treatment options, and patient involvement in decision making. Results: Participants noted that stigma and inadequate pain management created poor hospitalization experiences that contributed to self-directed discharge. On the other hand, patients reported hospitalization provided opportunities to connect to substance use disorder (SUD) treatment and protect them from outside substance use triggers. Many patients expressed interest in outpatient antimicrobial treatment options conditional upon perceived efficacy of the treatment, perceived ability to complete treatment, and available resources and social support. Finally, both patients and community partners emphasized the importance of autonomy and inclusion in medical decision making. Although some participants acknowledged their SUD, withdrawal symptoms, or undertreated pain might interfere with decision making, they felt these medical conditions were not justification for health care professionals withholding treatment options. They recommended open communication to build trust and reduce harms. Conclusion: Patients with IDU-associated infections desire autonomy, respect, and patient-centered care from healthcare workers, and may self-discharge when needs or preferences are not met. Involving patients in treatment decisions and offering outpatient antimicrobial options may result in better outcomes. However, patient involvement in decision making may be complicated by many contextual factors unique to each patient, suggesting a need for shared decision making to meet the needs of hospitalized patients with IDU-associated infections.

Telehealth has the potential to extend access to lifesaving treatment for opioid use disorder (OUD) among underserved people living with HIV (PWH). However, policymakers have scaled back pandemic-era telehealth provisions, citing concerns about safety and effectiveness. In this study of 42 PWH with OUD in one Deep South HIV clinic between 3/1/2020 and 4/30/2021, we used multivariable regression to assess the impact of telehealth utilization on patient-centered HIV and OUD outcomes. We found no significant difference in outcomes for those with high telehealth utilization versus others. In addition to being more accessible, telehealth does not appear to compromise health outcomes.