Integrating infectious diseases screening and treatment with medication assisted therapy for Veterans with opioid use disorder

Opioid use disorder (OUD) is associated with increased risk for overdose as well as acquisition and transmission of infectious diseases (ID) via injection drug use, including HIV, hepatitis C virus (HCV), and bacterial sexually transmitted infections (STI). Previous studies support improved clinical outcomes when integrating treatment for OUD and screening and treatment of HIV and HCV in non-Veteran populations. However, clinical care for Veterans with OUD often requires appointments with multiple different healthcare providers. These care silos place an increased burden on this patient population who often have barriers to appointment attendance. Improved integration OUD and ID clinical care is needed. In a study of Veterans with OUD who accessed care at the Northport VA we identified 216 (43%) Veterans who injected drugs and of those, 134 (62%) had HCV and 30 (13.9%) had at least one severe injection related infection requiring hospitalization. We also found low rates of screening for syphilis (n=371, 74%), gonorrhea (n=160, 31.9%), chlamydia (n=169, 33.7%) and uptake of HIV pre-exposure prophylaxis (PrEP) (n=4, 0.8%). In order to more thoroughly assess for gaps in VHA care delivery we must examine ID screening and PrEP uptake in a national cohort of Veterans with OUD who inject drugs. We must also clarify if there are any provider or Veteran barriers to ID screening receipt or PrEP uptake. For my CDA proposal I hypothesize that Veterans with OUD who are offered a care model that integrates OUD and ID clinical care will have increased rates of ID testing completion and initiation of PrEP. In specific aim 1, I will perform a retrospective study of ID epidemiology in a national cohort of Veterans with OUD who inject drugs. We will assess the proportion of Veterans who initiate PrEP (subaim 1A), proportion who completed screening for HIV, HCV and STI (subaim 1B), and compare the proportion of Veterans who received ID testing between multiple care settings (subaim 1C). Demographic factors (e.g. race/ethnicity, sex, geographic census, rural versus urban) will also be considered. In specific aim 2, I will complete a qualitative assessment of healthcare provider and Veteran specific barriers to uptake of ID screening and/or PrEP. Semi-structured interviews will be completed with providers in ID, primary care, and substance use disorder (SUD) clinics about knowledge of indications for screening for ID and PrEP in Veterans with OUD, as well as barriers to care delivery (subaim 2A). Veterans with OUD will be interviewed to inquire about experiences with receipt of ID screening and barriers to receipt of PrEP or ID screening at the Northport or West Haven VAs (subaim 2B). In specific aim 3 I will implement a pilot study that assesses feasibility and acceptability of an integrated ID screening and PrEP intervention for Veterans with OUD who are engaged in care through the Northport VA SUD clinic. We will randomize Veterans to receive either integrated care (HIV, HCV, STI screening and/or PrEP plus SUD care) or treatment as usual (SUD care plus ID clinic referral). We will compare rates of HIV, HCV and STI screening (subaim 1) as well as PrEP uptake (subaim 2) between the groups. This research will benefit male and female Veterans with OUD. This project will be carried out at the Northport Veterans Affairs Medical Center (NVAMC) (AIMs 1 and 3), the VA Connecticut Healthcare System (virtually or by phone, AIM 2), plus two additional VA sites (AIM 2), locations to be determined by AIM 1, under the co-mentorship of Drs. Sandra Springer (VA Connecticut) and Bettina Fries (NVAMC). Drs. Springer and Fries are experts in infectious diseases and are federally funded investigators with experience in clinical research. Both will guide my career development along with an advisory committee. Completion of the proposed project and career development plan will allow me to fulfill my short-term goals of gaining additional training in clinical research and long-term goals of becoming an independent physician-scientist, practicing infectious diseases (25%) and performing clinical research (75%) at the NVAMC. In addition to robust ID clinical training, I have the necessary research foundation to fulfill these goals including 1) ID clinical research training 2) Master of Public Health degree 3) Demonstrated publication success.