Hello, and thank you for joining the PCSS MAT training entitled medical considerations for patients with opioid use disorder. My name is Jeanette Tetrault. I'm an associate professor of medicine and the program director for the Addiction Medicine Fellowship at Yale University School of Medicine. I have no financial relationships to disclose. So at the conclusion of this activity, participants should be able to recognize skin and soft tissue infections in people who inject drugs. Educate individuals about risk factors and risk groups for hepatitis C and HIV. Describe prevention interventions for hepatitis C and HIV, including effective addiction treatment, behavioral risk reduction, and the use of antiviral agents. And lastly, discuss how treatment regimens for both hepatitis C and HIV are highly effective in patients with opioid use disorder and can be safely used with opioid agonist therapy. The overarching goal of the PCSS MAT is to make available the most effective medication assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. So we're going to start today's activity with a case which we'll revisit throughout the module. The case is patient JO. He's a 26-year-old man who has no primary care physician, who presents to urgent care clinic with a red, warm indurated area on his left forearm. He has a history of opioid use disorder and started using oxycodone-acetaminophen intranasally up to 180 milligrams daily at the age of 18. At the age of 22, he switched to heroin use intranasally as it was cheaper and more readily accessible. And then at the age of 24, he began using up to five to 10 bags of heroin intravenously daily. His other pertinent history. He has multiple female sexual partners and reports that he rarely uses barrier protection. He drinks three to four beers daily, most days of the week. So the question is what should we do now in addition to the discussion of treatment of the patient's opioid use disorder? >> So for patients like JO, who present to general medical settings, it's important to be sure to recognize skin and soft tissue infections in this patient population who inject drugs. Skin and soft tissue infections are the most common cause of hospitalization for people who inject drugs. Cutaneous and subcutaneous abscesses are the most common type of skin and soft tissue infection in this population. They're commonly found in sites of frequent injection, including the antecubital fossae, the groin, and the feet, as many patients may have lost access in other places and may be injecting in places like their groin and feet. Treatment of more superficial skin and soft tissue infections like cellulitis includes antibiotics directed towards commonly found skin microbes, including staph and strep species. We do need to have special consideration for Methicillin resistant staphylococcus orias coverage, and it's important to know your area microbiome coverage, and be sure to cover appropriately if you have a high index of suspicion that the patient may be presenting with MRSA. Treatment of abscesses, on the other hand, require incision and drainage. And this may need repeated INV with surgery often required because of pockets of deeper infection. Important to note that Poly-microbial infections may be found in over 50% of cases presenting with abscesses, and treatment should include coverage of anaerobes. >> When treating people who inject drugs for skin and soft tissue infections, it's necessary to consider important complications. And these include bacteremia, or sepsis, the sleeting of the bloodstream with the microbial agent. Seating of joints or heart valves, especially in patients with prosthetic joints or prosthetic heart valves. Or if they have a prior history of endocarditis or other infections. Patients may also seed sites as bone and develop osteomyelitis or discitis, and the discs in the back. Mycotic aneurysms may develop. Additionally, necrotizing fasciitis can be an important complication of cellulitis. And you have to have a high index of suspicion, and promptly get surgical intervention in these patients. And additionally, paraspinal abscess are something to consider. So if you are evaluating a patient with a skin and soft tissue infection who complains of other symptoms, take them seriously and consider these important potential complication and perform a workup as indicated. So what about our patient J.O.? If this in fact an abscess in his arm and wound care and packing are needed for this patient, we have to think of important considerations such as where does this patient live? Does he have somewhere to keep supplies to do packing? Or is there someone who the patient lives with who can be trained to pack the wound after its incised and drained? If not, it may be necessary to have the patient come back to the urgent care setting with frequency or a primary care setting with frequency to do that, and or involve visiting nurses. The patient should also be given the Tetanus-diphtheria-pertussis vaccine if it has not been performed within the last 10 years. And given the patient's lack of ongoing primary care, this [INAUDIBLE] care visit may be an ideal time to link the patient to primary care services and addiction treatment. And ideally, if those are in the same place, that would be most opportune for this patient. When seeing this patient presenting with this infection, you should also consider certain screening tests. So CBC and chemistries, urinalysis, given the patient's risk factors of injection drug use, we should also be checking liver enzymes, hepatitis C antibody, HIV screening, as well as screening for hepatitis B serologies. Given his multiple female sexual partners, and lack of barrier protection, we should be offering STD screening and consider screening for latent tuberculosis infection. So these screening tests are performed and come back, and we find that JO has a CBC which is unremarkable, chemistries and L-F-T-S are also normal. His hepatitis C antibody is reactive. HIV screening test is non-reactive Hep B surface antibody's nonreactive, Hepatitis B core antibody is nonreactive, and Hepatitis B surface antigen is also nonreactive. So this suggests our patient has been exposed to Hepatitis C infection, and has not been exposed or immunized for Hepatitis B. In terms of Hepatitis C, roughly 2.7 million people in the US are infected with Hepatitis C. And one-third of all people who inject drugs between the ages of 18 and 30 have cirrhologic evidence of Hepatitis C infection, meaning Hepatitis C antibody positivity. Greater than 70% of people who inject drugs age 30 plus years may have had exposure to Hepatitis C in some series. It's important to note that baby boomers, are those born between 1945 and 1965, account for 75% of all Hepatitis C infections. And it's speculated that up to 75% of those infected with Hep C may be unaware of their status. And this is important because Hepatitis B is the leading cause of cirrhosis, hepatocellular cancer, and reason for liver transplantation in this country. All of these conditions require a great deal of healthcare utilization. Again, necessitating the need for early screening and treatment. So when thinking about Hepatitis B transmission, important to think about specific risk factors and risk groups. So certainly, as mentioned, intravenous drug use is a common risk factor for the transmission of Hepatitis C infection. So too is intranasal drug use. So sharing of intranasal inhalation equipment, either straws or rolled up dollar bills, which may be exposed to blood products of one individual then shared with another, which may get into their bloodstream if they then nick their nose, their nasal mucosa, using the paraphernalia. Patients with multiple sexual partners, those who are HIV or Hepatitis B positive. And prior to 1992, blood transfusion and organ transplantation were considered risk factors prior to widespread screening of blood products and organ transplantation. And the risk groups, children born to Hepatitis C infected mothers, healthcare workers through occupational exposure, patients on hemodialysis, and patients who have a history of incarceration may be at higher risk. And so just sort of putting this all together, Hepatitis C is transmitted from blood to blood contact. So blood from one individual gets into the bloodstream of another individual, and these are the factors and groups where that can occur commonly. In terms of education, when we're discussing Hepatitis C transmission and natural history with patients, it's important to sort of demystify the process and expel any myths that have been out there about Hepatitis C. So on this slide we're going to go over what the natural history of Hepatitis C infection looks like. So anyone who is exposed to Hepatitis C virus develops an antibody, and that's how we screen for Hepatitis C. The majority of patients do go on to develop chronic Hepatitis C infection, upwards of 80 to 85% of those exposed to the virus develop chronic infection, as evidenced by Hepatitis C virus in their bloodstream. 15 to 20% do resolve the infection on their own, meaning although their Hepatitis C antibody is positive, they don't have detectable virus within their bloodstream. Of those with chronic infection, about 10 to 15% go on to develop the feared complication of cirrhosis, meaning irreversible scarring of the liver. Whereas, the majority of patients with chronic Hepatitis C infection have stable indolent, the progressive disease. As evidenced by virus in their bloodstream and some degree of fibrosis in their liver. And then of patients with cirrhosis, about 25% of those, or 2 to 4% of the entire population of folks with chronic Hepatitis C infection, go on to develop hepatocellular carcinoma and/or liver failure. Whereas, the majority of people with cirrhosis have slowly progressive disease. [COUGH] And there's no telling who's going to go on to develop cirrhosis or who's going to live with stable chronic Hepatitis C, but we do know certain factors place patients at higher risk of going on to develop cirrhosis. And those include other things that may affect the liver, such as alcohol or other viral Hepatitis. From the time of exposure to the time of the development of cirrhosis, the duration is anywhere from 10 to 20 years, depending on other risks for fibrosis within the liver. Once we identify patients with Hepatitis C or are dealing with a population of patients at high risk for Hepatitis C, we really need to be thinking about Hepatitis C prevention strategies. And this is a schematic adapted from a recent article in the current HIV/AIDS reports, which was looking at HIV prevention, but the same prevention strategies can be adapted to Hepatitis C prevention. So addiction treatment as an important arm for preventing the spread of Hepatitis C. Behavioral risk reduction, talking to patients about the ways that Hepatitis C can be transmitted, and how to protect themselves and others. And antiviral-based interventions treating Hepatitis C among patients who may be at risk for transmitting Hepatitis C to others. So this is sort of our three-tiered approach to preventing the spread of Hepatitis C. In terms of screening and testing, I mentioned that the initial screening test involves antibody testing by immunoassay. This is generally done through a blood draw, however, rapid testing and self-collection kits are available in some clinical settings. Previously, there was a confirmatory test called the recombinant immunoassay, or RIBA, which is no longer available in the United States. So current standard of care is, if a patient does have Hepatitis C antibody positive by immunoassay testing, the next steps would be to determine whether the patient has Hepatitis C virus in their bloodstream. This can be done either through qualitative testing, yes or no, is the virus present, or quantitative testing, which can then be Then go on to test the genotype of the hepatitis C infection in the patient. Now, certainly, if you have a patient that you're considering would be a treatment candidate for hepatitis C, I would recommend checking the quantitative viral load and genotype as this information is necessary for treatment planning. Liver Function Testing has long been considered in the heart of the screening for hepatitis C. And it's important to note that Liver Function Tests may be very variable in patients with chronic hepatitis C. So this is a graphic taken from a relatively old study published in hepatology where the authors looked at patients with chronic hepatitis C infection, known chronic hepatitis C infection, that over two years, 25 months of follow-up, they measured greater than or equal to 4 measurements of serum ALT, or one of the liver transaminases. Again, over two years. And they looked at roughly 1,000 patients, again, with chronic hepatitis C infection. And found that almost half of that population actually had persistently normal ALP. Another 43% had intermittently elevated ALT. And only 15% had persistently elevated ALT. This is a common myth that if patients have hepatitis C antibody positivity but normal ALTs, they're quote unquote carriers of infection. This is a myth that's been perpetuated for a long time. And this study shows that actually most individuals with chronic hepatitis C infection will have normal liver function tests, and we should not be using this as part of treatment planning or assessment of underlying degree of liver fibrosis. Certainly not in isolation. So once we've identified a patient with hepatitis C exposure, further workup would be necessary at this point. And again, if you have a patient that you're considering treatment, the following information is helpful. So checking the patient's hepatitis C quantitative viral load with genotype testing, which will help determine what treatment regimen the patient would undergo. Checking routine laboratories including CBC, basic metabolic profile, liver function tests, which can be helpful, again, in treatment planning, thyroid levels, checking the patient's prothrombin time, or INR if there are concerns for underlying cirrhosis. And certainly, checking a urine HCG, human chorionic gonadotropin, for women of child-bearing age to rule out pregnancy. We should also screen for other viral infections, including HIV, hepatitis A and B. And for those patients who have not been exposed to or vaccinated for hepatitis A and B, we should offer vaccination as appropriate. It's also important to get an assessment the patient's underlying degree of liver fibrosis. Classically, this was done with biopsy of the liver. However, now, many non-invasive testing methods are available including serologic testing or ultrasound transient elastography. Or biopsy, which would be considered the gold standard to which many of these tests are compared to. For patients who have evidence of cirrhosis either by biopsy or these non-invasive testing methods, those patients should be considered candidates for screening for esophageal varices and hepatocellular carcinoma. And this can be done in consultation with a gastroenterologist. It's also important and vital in these patients to review the addiction treatment plan. And consider reductions in alcohol and other drug use, and promoting abstinence through treatment. As well as ongoing discussions about harm reduction and Hepatitis C transmission. Similarly, we should be talking about prevention messaging for patients who are considering treatment for hepatitis C, including HIV prevention, hepatitis C transmission prevention, limiting the intake of hepatotoxins, including alcohol, and again, harm reduction counseling and risk reduction counseling. Still, the question remains is is JO a treatment candidate? Would JO be a treatment candidate? He's actively using heroin, as he told us when he presented to the urgent care center. So current HCV guidelines recommend that the goal of treatment is to reduce all cause mortality and liver related health adverse consequences by the achievement of virologic care which is evidenced by a sustained virologic response. Sustained virological response is documenting absence of hepatitis C virus after treatment and three months after treatment is completed. In terms of recommendations for when and in whom to initiate treatment, it is important to note that these guidelines recommend that treatment is recommended for all patients with chronic hepatitis C infection. Except those with short life expectancies owing to comorbid condition. Immediate treatment is assigned to those for the highest priority with advanced fibrosis, including those with compensated cirrhosis. Patients who've already received liver transplantation or patients with severe extra hepatic manifestations of hepatitis C. And immediate treatment should be prioritized as necessary for patients at high risk for liver related complications. We already talked about recommendations for pretreatment assessment and recommendation for repeat liver disease assessment is recommended such that ongoing assessment of liver disease is recommended for persons in whom therapy is deferred for whatever reason. So what about treatment in patients with active illicit substance use? So really, the barriers to hepatitis C treatment should include ability to adhere to medication. Comorbid psychiatric conditions that may limit the patient's ability to adhere. Risk of reinfection, which is thought to be relatively low. And insurance coverage consideration as the medications are very costly. So again,I'm just going to reiterate that the American Association for the study of liver disease and HCV guidelines suggest that hep C treatment should not be withheld from those who actively use illicit substances or are enrolled in a substance abuse treatment program. So again, as long as you have patients that can adhere and you can engage in harm reduction, counseling, and referred treatment, they should be not be Excluded from treatment. And point in case, hepatitis C treatment cascade has shown that of folks who are chronically infected with hepatitis C infection, roughly 50% are diagnosed and aware of their status. And if you go down the line, only about 15, 16% are prescribed hepatitis-C treatment and only 10% of the total population achieve virologic cure. These numbers are changing a bit with the changing landscape of hepatitis C treatment options, but nonetheless, it's important to get these patients into care and considered for treatment. So what about treatment? Hepatitis C treatment has evolved greatly over the past several years. Prior to 2013, the standard of care was pegylated interferon and ribavirin, which had a long duration of therapy, anywhere from 24 to 72 weeks. The standard treatment course was 48 weeks. The likelihood of achieving virologic cure or sustained virologic response was anywhere from 50 to 70% and not considered very favorable. And that treatment regimen has extensive side effects with high rates of treatment discontinuation. In 2013, the early protease inhibitors were introduced, and these included telaprevir and boceprevir. These medications decreased treatment duration and improved efficacy of likelihood of establishing a sustained virologic response. However, they still required interferon and still had a pretty extensive side effect profile. And then in 2014, everything changed with the introduction of polymerase inhibitors, which drastically reduced treatment duration, down to 8 to 24 weeks, improved efficacy of the establishment of a sustained virologic response up to 90 to 98%. And the medications were all oral, requiring no interferon. There was a reduced side effect profile, and the downside has been high cost of the medication, although cost is starting to come down with newer medications on the market. So when considering treatment regimens, as I had mentioned earlier, it's important to know the patient's genotype, the presence or absence of cirrhosis. Any comorbidities that the patient may have, consider contraindications for treatment, of which there are few. Understand medication interactions, as there are many interactions with many of the commonly used hepatitis C medications. And for some medication regimens, understand the presence or absence of baseline resistance for certain treatments. And lastly, it's important to know whether the patient has been previously treated with either interferon containing regimens or the newer direct-acting antivirals. So because this landscape is changing commonly, I'm not going to go through all of the available treatment regimens. Just know that there are different classes. There's NS3/4A protease inhibitors, NS5A inhibitors, and NS5B RNA polymerase inhibitors. All of which are effective, and most of the current regimens include a combination of two to three medications. These are just some examples of medications that are used based on genotype and the duration of treatment. Again, the likelihood of achieving SVR, a sustained virologic response, upwards of 90 to 99%. Relatively favorable side effect profile in comparison to hepatitis C treatment with interferon-based regimen. And it's important to note that many drug interactions are possible. And so having an active medication list, performing a medication reconciliation on patients, and consulting with a pharmacist if needed to be sure that the interactions are minimized. So back to our patient, J.O., he's found to have 3 million copies of hepatitis C virus genotype 1a, which happens to be the most common in this country. Liver fibrosis testing reveals approximately F1 fibrosis. Again, this is early fibrosis, F4 would be considered cirrhosis. He's initiated on ledipasvir/sofosbuvir combination treatment, which is one pill once a day for eight weeks. And he had enrolled in a methadone treatment program, and his medication was actually initiated on maintenance methadone treatment program. He cleared the virus at the end of treatment. And three months after the end of treatment, he was found to have an undetectable viral load, or establishment of virologic cure, or sustained virologic response. Unfortunately, after three years of consistent engagement in treatment for his opioid use disorder, he became lost to follow-up. He returned to care to reinitiate treatment, but he reported that he was injecting again five bags of heroin daily. He denied any needle sharing, but reported unprotected sex with multiple female partners. He's found on routine screening to have established HIV infection. And his hepatitis B antibody remains positive, but viral load quantitative testing is negative. And this is a very important point in that hepatitis C antibody will remain positive in patients who've undergone treatment and cleared the virus. And so quantitative testing or qualitative viral load testing is necessary to confirm the patient has been re-exposed. So unfortunately, J.O. has been treated for hepatitis C and remains hepatitis C negative, but now has been exposed to HIV. And this slide just shows the natural history of HIV infection, [COUGH] where primary infection leads to very high plasma viral load levesl, shown in red, and initially relatively normal looking CD4 count levels. As time progresses, the CD4 lymphocyte cell counts decrease and the patient can go on to develop opportunistic infections and AIDS. [COUGH] So what about HIV screening? In 2006, the CDC issued new guidelines which recommended certainly one time screening for all adults, all folks age 13 to 64, unless there's a very low documented prevalence. One time screening for patients initiating tuberculosis treatment, or for any patient seeking treatment for a sexually transmitted infection. And one of the major changes of these guidelines was this screening should be offered in an opt-out approach. So normalizing screening and giving the patients the opportunity to opt-out, but not necessarily having to go through a prolonged consent process to be able to screen. After one time screening, repeat screening, at least annually, should be performed in people with injection drug use and their sex partners. Persons who exchange sex for money or drugs, sexual partners of those with known HIV infection. Men who have sex with men, and heterosexual individuals, who themselves or their partner have greater than one sex partner since their last HIV test. So again, much more widespread screening and an opt-out approach. The screening algorithm has also changed, such that initial screening nowadays is done through HIV antigen/antibody combination immunoassay. And if this test is negative, it's considered negative. We no longer have to rely on Western Blot testing. These fourth generation tests have improved sensitivity and specificity, though it is important to note it still may miss infection if it was within ten days of acquisition. And for a positive test, it can differentiate between HIV-1 or HIV-2 infection. So this will look familiar to the module participants, as this is the same sort of rubric that we think about for Hepatitis C and HIV prevention strategies. So, again, when dealing with certain populations, HIV transmission prevention can be established and prevented with comprehensive addiction treatment. Behavioral risk reduction counseling, which includes both risk reduction related to substance use, but also sexual exposure. And antiviral-based interventions ,which not only treat HIV, but also can be used in a prevention setting, in which it's differentiated antiviral-based interventions for Hepatitis C prevention. And we'll get into that in a moment. So when thinking about how opioid agonist treatment may be a approach to helping decrease the spread of HIV. This is a systematic review, which was published in 2012, looking at nine studies and representing over 23,000 person years of individuals on methadone treatment. And they found that opioid agonist treatment with methadone resulted in a 54% reduction in HIV incidence. Again, by treating patients for their opioid use disorder can actually decrease the spread of HIV infection, especially in high prevalence areas. Similarly, buprenorphine treatment may have an effect. And this is a graphic taken from a study looking at the prevalence of HIV risk factors among patients treated with buprenorphine over a year. And this shows a decrease in both needle sharing and unprotected sex over a year of buprenorphine treatment in patients involved in clinical care. Again, two risk factors which are important to consider in the spread of HIV infection. So the next tier for HIV prevention includes behavioral risk reduction. So in addition to counseling based intervention, needle and syringe programs have shown sufficient evidence to support effectiveness in reducing injection related behavior. And tentative evidence supports effectiveness in preventing the transmission of HIV. And there's emerging evidence for other interventions, including syringe exchange and syringe availability in pharmacies, vending machines. Also some data looking at supervised drug consumption and injecting facilities, of which there's even consideration in some US cities for these types of facilities. As well as counseling and educational intervention, both within the context of primary care and added on to other general medical settings. When we think about antiviral interventions for decreasing HIV transmission, in addition to treating people with active HIV infection with antiviral regimens, we also have the option of pre-exposure prophylaxis, or PrEP for HIV. And PrEP is a combination of two antiviral medications, which is taken once daily. It's a combination pill of Emtricitabine and Tenofovir. There are no reported drug-drug interactions with methadone, buprenorphine, or naltrexone of this combination treatment. It was FDA approved in July 2012 for HIV prevention, and was added to the CDC guidelines in 2014. It's indicated for men who have sex with men, for folks with high risk sexual contact, and for persons who inject drugs. And much of the data on this approach was taken from the Bangkok Tenofovir Study, which looked at HIV-negative individuals with injection drug use. [COUGH] And they found that HIV incidence decreased by 49% in this population of HIV negative people with injection drug use, and also risk behaviors decreased. So I mentioned that pre-exposure prophylaxis is indicated for men who have sex with men, for heterosexual women and men with high risk sexual exposure, and for people who inject drugs. And this table is a nice reference to determine who may be a candidate for PrEP, which is listed here in the top row of the table. Clinically eligible patients need to have documented HIV negative test before prescribing this medication. They need to have no signs or symptoms of acute HIV infection. And because Emtricitabine and Tenofovir may affect renal function, >> Clinically, all the eligible patients should have normal renal function and no other contraindicated medications prior to obtaining a prescription. Additionally, documented hepatitis B negativity and, or vaccination status is appropriate. And when prescribing Emtricitabine and Tenofovir, it should be an oral oral dose one pill once a day. No more than a 90-day supply should be given to patients and the patients should have followup visits at least every 3 months and provide HIV testing, medication adherence counseling, behavioral risk reduction support, side effect assessment and assessment for other sexually transmitted diseases. Renal function should also be assessed periodically throughout treatment and patients, again, should be tested for bacterial STDs based on certainly their risk behaviors and risk groups. And again, it's important to note that pre-exposure prophylaxis is one pill once a day taken every day. Not just prior to events where they may be exposed to HIV. So when thinking about our patient, J.O. with opioid use disorder who was recently treated for hepatitis C infection and cleared, who had a relapse to opioid use and now has documented HIV infection. As a provider, we need to think about when should we start treatment for his HIV? What are the options for this newly diagnosed patient and what are some important considerations regarding HIV care among patients with opioid use disorder? So [COUGH] this guidance was adapted from the DHHS guidelines on HIV/AIDS treatment. And again, the goals of treatment of HIV infection are to reduce morbidity and prolonged duration and audience survival. To restore and preserve immunologic function. To maximally and durably threat suppress that plasma HIV viral load, and to prevent HIV transmission to others. And in regards to our first question when to initiate treatment, treatment is recommended for all HIV infected patients regardless of their CD4 cell count. Patients who are being considered to initiate an antiretroviral treatment for HIV should be willing and able to commit to treatment and understand the risks, and benefits as well as importance of insurance. There are some baseline evaluation testing that should be performed similar to prior to starting hepatitis C treatment. And with treatment, educational counseling and risk reduction, behavioral risk reduction counseling are important. In terms of treatment options for antiretroviral treatment naive patients, there are currently five recommended first line agents for treatment naive patients. And those include four integrase inhibitor combinations listed in the first four row of the table and one boosted protease inhibitor-based regimen. There are some things to consider with some of the treatment regimens in terms of HLA-B5701 testing and looking at renal function. But otherwise, these would be the first line treatment regiments that would be considered in newly diagnosed HIV naive treatment patients. One thing we always have to consider with antiretroviral medication is any potential interactions, especially with medications used to treat opioid use disorder. So methadone which is metabolized by cytochrome P450, ISO enzymes to be 63A42D6 does have some interactions with older antiretroviral medications used to treat HIV and these include a fabricates nevirapine and some of the older protease inhibitors. Buprenorphine which is metabolized by cytochrome p for 53A4 does have some concern for interaction with the protease inhibitor atanazavir, which may decrease levels. However, this is not known to be clinically significant. And Naltrexone, which is not metabolized by the cytochrome system shows no significant interactions expected or observed with antiretroviral treatment options. [COUGH] So it's been documented that there exists suboptimal care for people with injection drug use along the HIV treatment cascade. Again, approximately over 14,000 folks with injection drug use may be aware unaware of their HIV status at testing is not necessarily routine and opioid treatment programs and may in fact be decreasing. So in one series, they looked at testing practices in opioid treatment programs which actually decreased in 2005 from 93% to 64% in 2011 despite improvement in screening strategies. Additionally, we know the population of patients who inject drugs may be less likely to initiate antiretroviral therapy and may have lower quality care of those who go on to get treatment they may be less likely to achieve viral suppression and or be retained in ongoing HIV care. >> A potential solution to address the gaps in care for this population include integrated addiction and HIV care. In 2011, the Health Research Services Administration launched a special problems of national significance project which included integration of opioid treatment and HIV clinical care within 10 sites across the United States and within the over 300 patients were represented. And this project overall showed that at 12 months, nearly 50% of patients were engaged in addiction treatment. Among those who were receiving treatment, past 30 day elicit opioid use decreased from 80 4% to 42%.. Additionally, among those retain Medicare, buprenorphine was associated with an increased likelihood of initiating and remaining on antiretroviral treatment and establishing HIV viral suppression. So taken together, these projects showed and demonstrated feasibility of delivering integrated care as an effective treatment strategy for patients with both opioid use disorder and HIV. So what about those patients who present with hepatitis C and HIV co-infection? Sort of unlike our patient who presented initially with hepatitis C, cleared, and then presented with HIV. So it's important to know that significant drug to drug interactions may occur between treatments used for HIV, and hepatitis C, and possibly opioid use disorder treatment. And therefore, patients should be cared for in collaboration with an HIV practitioner or a infectious disease specialist. Additionally, co-infected person should be treated and re-treated the same as persons without HIV infection after recognizing and managing interactions with any potential antiretroviral medicines. So in summary, people who inject drugs are at high risk for skin and soft tissue infections as our patient JO presented with, which can result in serious complications. People living with opioid use disorder are at increased risk for hepatitis C and HIV due to needle sharing and sexual risk behaviors. Comprehensive prevention interventions for both HCV and HIV include addiction treatment, behavioral risk reduction, and antiviral agents. Routine screening is essential for timely diagnosis and treatment regimens for both hepatitis C and HIV are highly effective in patients with opioid abuse disorder and can be safely used with opioid agonist therapy provided medication interaction charts are referenced. Over the next couple slides are a series of references that I have suggested throughout the talk and some others that may be useful reading on this topic. And I just want to make you aware of two resources offered through the PCSS-MAT that may be of interest to those participants taking part in the module today. First, PCSS-MAT mentor program is designed to offer mentoring assistance to those in need of more one on one interactions with one of our colleagues to address any clinical questions that arise. Through this program, you have the option of requesting a mentor from our mentor directory, or we're happy to pair you up with one. And to find out more information, please visit our website using the web link noted on this slide. Another potential resource is a PCSS which offers a discussion forum which is comprised of our PCSS-O and PCSS-MAT mentors, and other experts in this field, who provide prompt responses to clinical cases or questions. We also have a mentor on-call each month, that is available to address any submitted questions through the discussion forum. You can create a new login account by clicking on the image on this slide to access the registration page. And lastly, I just wanted to show this slide which simply notes the consortium of lead partner organizations that are part of PCSS-MAT project. As well as our contact information, website, and Twitter and Facebook handles to find out more about what we offer. Thank you so much for your participation in this module. Have a wonderful day.
