Ending HIV in the United States Will Require a Substantial Financial Commitment

image of small red ribbon on a beige shirt

Photo by Anna Shvets from Pexels.

“What will it take to end HIV in the United States?” is a pressing question posed by public health officials, researchers, and policymakers alike. Population Data & Modeling Core Director Benjamin Linas seeks to answer that question by amplifying notable results from a simulation modeling study published by researchers at Johns Hopkins. In an editorial issued in the Annals of Internal Medicine, Linas underscores the urgency to expand comprehensive and population-wide HIV interventions to reduce HIV transmission.

Linas argues, “First, if the United States continues on its current trajectory, it will not end the HIV epidemic. This is not the only analysis to highlight that grim reality, nor is it the only approach to reaching that conclusion, but it is a clarion call that must be reiterated.”  Linas is also an infectious diseases physician, professor of medicine, and the director of the HIV Epidemiology and Outcomes Research Unit in the Department of Medicine at Boston Medical Center.

photo of benjamin linas

Population Data & Modeling Core Director Benjamin Linas

To end the HIV epidemic by the year 2030, he stresses a need to increase funding for comprehensive intervention packages for a wider population, but the optimal mix of interventions is not the same for every jurisdiction. What it will take, Linas advises, is coordinated and committed action from local and state decision-makers alongside a substantial increase in funding.

Read the full editorial at the Annals of Internal Medicine.

Virtual Conferences to Attend This Month

close up of hands typing on a laptop

Photo by Christina Morillo from Pexels.

This fall, join CHERISH investigators, CHERISH Research Affiliates, Advisory Board members, and pilot grant recipients on the virtual stage as they present their research at upcoming conferences. Use the following schedule to connect with CHERISH colleagues and explore the breadth of their work.

Please visit each conference site for the latest information.

logo of AHSR 2021 conference

Addiction Health Services Research Conference (AHSR) 2021

October 13 - 15, 2021
The AHSR program and the schedule below are in
Eastern Daylight Time (EDT).
* = presenter/speaker

logo of INHSU 2021

International Network on Health and Hepatitis in Substance Users (INHSU) 2021

October 13 - 15, 2021 AEDT
The INHSU program is in Australian Eastern Daylight Time (AEDT).
The schedule below is in Eastern Daylight Time (EDT).
* = presenter/speaker

logo of Society for Medical Decision Making (SMDM) 43rd Annual North American Meeting

Society for Medical Decision Making (SMDM) 43rd Annual North American Meeting

October 18 - 20, 2021
All scientific sessions are viewable through January 14, 2022.
The SMDM program and the schedule below are in
Eastern Daylight Time (EDT).

logo of AMERSA annual conference

AMERSA Annual Conference

November 3 - 5, 2021
The AMERSA program and the schedule below are in
Eastern Daylight Time (EDT).

Drug User Health Hubs in New York State: Results of a Qualitative Study Describing Services Offered in a Novel Co-located Harm Reduction and Treatment Model

Authors: Ude M,  Behrends CN, Gelberg K, Goldberg R, Kelly S, Chung R, Leung S, Schackman BR, Kapadia SN

photo of czarina behrends  Profile photo of Dr. Bruce Schackman  photo of shashi kapadia

Czarina Behrends, PhD, MPH, Bruce Schackman, PhD, MBA, and Shashi Kapadia, MD, MS

Weighing the Costs and Benefits of Initiating Extended-release Injectable Naltrexone Compared to Buprenorphine-naloxone

close up of a provider's softly clasped hands

Photo from Cottonbro by Pexels.

Naltrexone and buprenorphine are two effective medications for opioid use disorder (OUD). Naltrexone, which is typically given as a monthly extended-release injection (XR-NTX), and daily oral buprenorphine, which is typically combined with naloxone (BUP-NX), are prescribed in outpatient or office-based medical settings. XR-NTX patients, however, need to complete detoxification before starting treatment.

Results from a national clinical trial, X:BOT, published in January 2018, showed it was more difficult to initiate patients in inpatient and residential settings on XR-NTX than BUP-NX. Both medications were found to be equally safe and effective for those who successfully initiated treatment.

Investigators and colleagues associated with the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) conducted primary and secondary economic analyses using data collected from the X:BOT trial. They measured the cost, quality of life impact, and cost-effectiveness of initiating XR-NTX and BUP-NX in inpatient and residential treatment programs.

The following fact sheet summarizes key economic implications of each treatment and offers recommendations for policymakers, providers, and healthcare systems to effectively deliver XR-NTX and BUP-NX.

Intern Spotlight: Sona Fokum and Weston Lowry

This summer, Sona Fokum and Weston Lowry are interning at the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) and expanding their research experience by working alongside CHERISH investigators and colleagues. Both Fokum and Lowry are pursuing careers in healthcare and recognize that this experience will provide foundational insights about health economics and policies related to caring for vulnerable communities, addressing health inequities, and combatting the opioid crisis. CHERISH is committed to engaging diverse students and trainees at all levels in health economics and substance use research, and we are delighted to have Fokum and Lowry on board.

portrait photo of sona fokum

Based in Chicago, Illinois, Sona Fokum enjoys the vibrant range of activities offered by the city including scenic walks by Promontory Point.

Sona Fokum

Sona Fokum is a rising senior from the University of Illinois at Chicago. Complementing her public health studies with a double minor in biological sciences and chemistry, she seeks to ground her understanding of the political and environmental conditions that impact how healthcare is delivered and accessed. She plans to obtain a dual MD/MPH degree in the future.

Through the Summer Undergraduates Minority Research Program at the University of Pennsylvania, she is working with CHERISH investigator Jake Morgan and CHERISH Dissemination & Policy Core Director Zachary Meisel on identifying best practices to create linked-records public health databases that will inform policies and interventions to address the opioid epidemic. She will be conducting literature reviews and coordinating qualitative efforts with stakeholders across 10 states to understand the processes behind combining linked-records databases.

portrait photo of weston lowry

Based in Minneapolis, Minnesota, Weston Lowry praises his hometown for the diverse food scene and the eclectic Minnesota State Fair.

Weston Lowry

Weston Lowry was a pre-med student who recently graduated from Yale University. Throughout his academic studies, Lowry progressively enriched his understanding of substance use in the United States. From interning at the Centers for Disease Control, and Prevention, to completing his senior thesis on the origins of syringe service programs, he is eager to contribute to the public health response to substance use and learn more about the substance use research community.   

Sponsored by the National Institute on Drug Abuse (NIDA) Summer Research Internship Program, Lowry will take part in data collection, manuscript preparation, and presentation of research findings under the guidance of CHERISH Director Bruce Schackman, CHERISH Research Affiliate Czarina Behrends, and Cristina Chin, research manager in the Division of Comparative Effectiveness and Outcomes Research at Weill Cornell Medicine. The study, “Feasibility and Acceptability of HIV, HCV, and Opioid Use Disorder Services in Syringe Service Programs,” aims to describe the healthcare delivery models of syringe service programs that provide medications and services for people with HIV, hepatitis C, and opioid use disorder.

Patient Preferences Do Not Explain Racial Disparities in Opioid Prescribing

Why are Black patients less likely than white patients to be prescribed opioids for acute pain in the emergency department (ED)?  While many theories have been put forward (ranging from racial differences in patients’ pain management preferences to providers’ false beliefs in biological differences between racial groups), the specific mechanisms underpinning these disparities are unclear.

We used data collected for Life STORRIED, a multicenter randomized controlled trial (RCT)  to clarify the role of patient pain management preference and to test the effectiveness of an intervention in reducing these disparities. We studied 1,302 patients presenting to the EDs of four academic medical centers with acute musculoskeletal back pain or renal colic. Even in the controlled setting of an RCT, we found that Black patients presenting to the ED were less than half as likely as similar white patients to be prescribed opioids for acute pain.

Patient preferences did not seem to explain this disparity. We found nearly identical disparities among patients who preferred opioids and among those who did not prefer opioids. Even among patients who preferred to not receive opioids, white patients were more likely than Black patients to be prescribed opioids.

Next, we tested the effectiveness of an intervention in reducing this disparity. Previous research, primarily in the area of employment discrimination, has proposed a theory called statistical discrimination. According to this theory, disparities emerge when decision makers apply generalizations about a group to individual members of that group to fill in a knowledge gap. Inaccurate statistical discrimination occurs when generalizations are based on false beliefs about a group. We hypothesized that this theory of discrimination may have particular relevance in the ED where providers are often missing important data about the patients who they are treating.

To test whether statistical discrimination may play a role in generating opioid prescribing disparities, we analyzed the impact of a clinician-facing intervention that consisted of a display containing information about each enrolled patient’s analgesia treatment preference, as well as the risk of future opioid misuse (see figure below for a sample display). We found that, even when providers were shown information about their patients’ treatment preferences and risk of misusing opioids, Black patients remained less likely to be prescribed opioids.

infographic indicating opioid risk assessment

Figure 1. Example of Opioid Risk Assessment

When we analyzed our data based on opioid preference and enrollment in our treatment arm, an unexpected pattern emerged; among those who did not prefer opioids, White patients were more likely than Black patients to receive a prescription for opioids in the treatment arm (in which clinicians were given additional information about their patients’ preferences and opioid-related risks) but not in the control arm.

Our findings suggest that statistical discrimination is not generating these disparities. In fact, we found that providing prescribers with additional information about their patients was associated with increased disparities among patients who did not prefer opioids. Most patients in our sample had very low opioid risk scores, so one potential explanation is that providers applied this additional, largely reassuring data in a biased and differential way in their interactions with Black and white patients.

Safe opioid prescribing is important, especially given the ongoing opioid overdose crisis. It is also important, however, that opioid stewardship efforts do not worsen access to effective pain control for Black patients. With the goal of achieving both equitable and safe access to opioids, further work is needed to design and test interventions to mitigate structural racism and disparities in acute pain management.

This article originally appeared on the University of Pennsylvania Leonard Davis Institute Health Policy$ense blog.

The study, Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial, was published in JAMA Network Open on July 29, 2021.  Authors include Eden Engel-Rebitzer, Abby R. Dolan, Shoshana Aronowitz, Frances S. Shofer, Max Jordan Nguemeni Tiako, Marilyn M. Schapira, Jeanmarie Perrone, Erik P. Hess, Karin V. Rhodes, Venkatesh R. Bellamkonda, Carolyn C. Cannuscio, Erica Goldberg, Jeffrey Bell, Melissa A. Rodgers, Michael Zyla, Lance B. Becker, Sharon McCollum, and Zachary Meisel.

Hospitalization as a Reachable Moment for Patients with Opioid Use Disorder

Imagine a medication that reduces morbidity and mortality from a disease that affects more than two million people in the United States. The medication drastically improves quality of life for those who take it and reduces costs to the health care system. For hospitalized patients, this medication decreases the chance of being readmitted and of dying after discharge. This medication can be picked up from a pharmacy and taken at home, and generic versions are available. Why then, is this medication notoriously difficult to access?

Perhaps it is because this medication is buprenorphine, which does not cure cancer or prevent Alzheimer’s disease, but instead makes living with opioid use disorder (OUD)—a chronic, often-relapsing disease—feasible. While buprenorphine has been around for nearly two decades, a variety of systemic and societal factors largely rooted in stigma make it inaccessible, especially for people of color and those living in rural areas. While a variety of efforts are needed to address the opioid overdose crisis, one promising strategy is to leverage hospitalization to initiate patients on buprenorphine.

A Reachable Moment

Why consider hospitalization a “reachable moment”? Patients with OUD are often hospitalized for extended periods of time due to discharge challenges (e.g., skilled nursing facilities may not accept patients with substance use disorders) or severe morbidity (e.g., recovering from cardiac surgery for endocarditis). Our team recently conducted a systematic review of hospital-based interventions for patients with OUD. Many interventions used interdisciplinary or multidisciplinary teams that variously included peers with lived experience, social workers, registered nurses, psychiatrists, and internal medicine as well as addiction medicine physicians. As expected, interventions generally focused on linkage to medication for OUD like buprenorphine or methadone during hospitalization and connection to post-discharge OUD care. Results were mixed regarding the impact of existing interventions on outcomes such as improving rates of in-hospital initiation of and post-discharge connection to medication for OUD and decreasing rates of health care utilization and discharge against medical advice. Interventions with the best evidence for improving outcomes facilitated connection to post-discharge OUD care and employed an Addiction Medicine Consult service. The review highlights the need for OUD-related interventions for hospitalized patients with OUD, though existing interventions may need to be adapted or refined to ensure that they are equitably improving meaningful outcomes.

This article originally appeared on the University of Pennsylvania Leonard Davis Institute Health Policy$ense blog with further details on policy considerations.

The paper, Interventions for hospitalized medical and surgical patients with opioid use disorder: A systematic review, was published in Substance Abuse on July 21, 2021.  Authors include Rachel French, Shoshana Aronowitz, J. Margo Brooks Carthon, Heath D. Schmidt and Peggy Compton.

Pilot Grant Recipients Receive Funding to Examine Health Disparities Related to the Treatment of Substance Use Disorders, HCV, and HIV

Profile image of Shoshana Aronowitz

Follow Shoshana Aronowitz, PhD, MSHP, FNP-BC, on Twitter @shoshiaronowitz.

Shoshana Aronowitz, PhD, MSHP, FNP-BC

Shoshana Aronowitz is a family nurse practitioner, community-engaged health services researcher, and assistant professor in the Department of Family and Community Health at the University of Pennsylvania School of Nursing. Her research examines innovative delivery models to promote equitable access to substance use treatment and harm reduction services, as well as racial disparities in pain management in the context of the opioid overdose crisis. In one of her latest publications, she evaluated a partnership between two community-based organizations and the Philadelphia Department of Public Health that provide free mailed naloxone kits and other harm reduction supplies to Philadelphians.

With the guidance of the CHERISH Dissemination & Policy Core Director Zachary Meisel and CHERISH Research Affiliate Laura Starbird, Aronowitz’s pilot project, “An Exploration of Barriers and Facilitators to Buprenorphine Access via Telehealth,” will study low-barrier treatments for substance use disorder and expand healthcare services to marginalized populations who use drugs.

Aronowitz provides opioid use disorder treatment at Prevention Point Philadelphia and Ophelia Health and is a harm reduction community organizer with SOL Collective. She received her undergraduate degree from McGill University and earned her master’s and doctoral degrees from the University of Vermont and University of Pennsylvania. She completed her postdoctoral fellowship at the National Clinician Scholars Program University of Pennsylvania site.

Profile photo of Ravi Gupta

Follow Ravi Gupta, MD, on Twitter @rgupta729.

Ravi Gupta, MD

Ravi Gupta is an internal medicine physician and National Clinician Scholars Program fellow at the University of Pennsylvania. His research focuses on evaluating policies on the use of prescription drugs and has been published in several high-impact journals. Notably, his investigation into rising naloxone prices led to congressional investigations of companies that manufacture naloxone.

Under the mentorship of the CHERISH Dissemination & Policy Core Director Zachary Meisel and former pilot grant recipient Austin Kilaru, Gupta’s pilot project, “Adoption of Extended-Release Buprenorphine Monthly Injections for Opioid Use Disorder,” will allow him to further examine the potential of extended-release buprenorphine and how racial disparities influence treatment adherence for people with opioid use disorder.

He received his undergraduate degree from Ohio State University, graduated from Yale School of Medicine, completed his clinical residency at Johns Hopkins Hospital in the Urban Health track, and practices medicine at the Corporal Michael J. Crescenz VA Medical Center.

Profile image of Thanh Lu

Follow Thanh Lu, PhD, on Twitter @thanh2lu.

Thanh Lu, PhD

Thanh Lu is a postdoctoral researcher in the Division of Comparative Effectiveness and Outcomes Research in the Department of Population Health Sciences at Weill Cornell Medicine and a CHERISH Research Affiliate. Lu has robust expertise in conducting economic analyses with a range of data sources including emergency department encounters, hospital discharge records, and surveys. One of her recent publications examined the relationship between recreational marijuana laws and household spending on food and alcohol.

Under the guidance of CHERISH Methodology Core Co-director Sean Murphy and Yiye Zhang, assistant professor in the Department of Population Health Sciences, Lu’s pilot project, “Stimulant Use Disorder Treatment Paths and Factors Contributing to Health Disparities,” will allow her to identify driving factors that exacerbate health disparities in treatment outcomes related to stimulant use disorder and address the emerging public health concern of stimulant-related overdoses.

Lu received her undergraduate degree from the Clarion University of Pennsylvania and graduated from Temple University with a master’s and doctoral degree in economics.

Follow Xiao Zang, PhD, on Twitter @XiaoZang5.

Xiao Zang, PhD

Xiao Zang is a postdoctoral research associate in the Department of Epidemiology at Brown University where he has demonstrated expertise in disease simulation modeling, model calibration, and health economic evaluation. Working with his postdoctoral supervisor CHERISH Research Affiliate Brandon Marshall, Zang has led valuable research projects including examining the impact rural syringe service program closures have on the HIV epidemic in Indiana, and the development of a microsimulation model to inform community-level naloxone distribution strategies to minimize opioid overdose fatalities.

With the mentorship of Marshall, Zang’s pilot project, “Improving Health Equity and Naloxone Access Among People at Risk for Opioid Overdose: A Distributional Cost-Effectiveness Analysis of Community-Based Naloxone Distribution Strategies,” will offer him an opportunity to evaluate and improve naloxone access for different racial and ethnic groups.

Zang received his undergraduate degree from Southeast University in China and a master’s degree in industrial and systems engineering from the University of Southern California. He earned his doctoral degree in health sciences from Simon Fraser University in Canada.