Yale University School of Medicine, New Haven, CT, USA.
Yale University School of Medicine, New Haven, CT, USA; APT Foundation, New Haven, USA.
Int J Drug Policy. 2022 Mar;101:103570. doi: 10.1016/j.drugpo.2021.103570. Epub 2021 Dec 20.
Healthcare delivery was disrupted during the COVID-19 pandemic, requiring minimized in-person contact between patients and clinicians. During the pandemic, people with opioid use disorder (OUD) were not only at elevated risk for COVID-19, but had markedly reduced access to treatment for OUD, Hepatitis C virus (HCV) and HIV due to recommended decreased in-person visits.
From March 15-June 15, 2020 at the syringe services program (SSP) in New Haven, Connecticut, USA, a differentiated care model evolved with reduced clinical demands on people who inject drugs (PWID) to ensure screening and treatment for HCV, HIV and OUD, with a focus on HCV treatment. This model involved a single, bundled screening, evaluation, testing (SET) and monitoring strategy for all three conditions, minimal in-person visits, followed by tele-health communication between patients, outreach workers and clinicians. In-person visits occurred only during induction onto methadone and phlebotomy at baseline and phlebotomy 12 weeks post-treatment for HCV to measure sustained virological response (SVR). Patients received supportive texts/calls from outreach workers and clinicians.
Overall, 66 actively injecting PWID, all with OUD, underwent bundled laboratory screening; 35 had chronic HCV infection. Participants were 40 years (mean), mostly white (N = 18) men (N = 28) and 12 were unstably housed. Two were lost to-follow-up and 2 were incarcerated, leaving 31 who started pan-genotypic direct-acting antivirals (DAAs). The mean time from referral to initial phlebotomy and initiation of DAAs was 6.9 and 9.9 days, respectively. Fourteen additional patients were newly started on buprenorphine and 6 started on methadone; three and four, respectively, were on treatment at baseline. Overall, 29 (93.5%) PWID who initiated DAAs achieved SVR; among unstably housed persons the SVR was 83.3%.
In response to COVID-19, an innovative differentiated care model for PWID at an SSP evolved that included successful co-treatment for HCV, HIV and OUD using a client-centered approach that reduces treatment demands on patients yet supports ongoing access to evidence-based treatments.
在 COVID-19 大流行期间，医疗保健服务受到了干扰，需要尽量减少患者和临床医生之间的面对面接触。在大流行期间，患有阿片类药物使用障碍（OUD）的人不仅面临 COVID-19 的风险增加，而且由于建议减少面对面就诊，他们获得 OUD、丙型肝炎病毒（HCV）和 HIV 治疗的机会明显减少。
在美国康涅狄格州纽黑文的注射器服务项目（SSP）中，从 2020 年 3 月 15 日至 6 月 15 日，出现了一种差异化的护理模式，对注射吸毒者（PWID）的临床需求有所减少，以确保对 HCV、HIV 和 OUD 进行筛查和治疗，重点是 HCV 治疗。这种模式涉及到针对所有三种疾病的单一、捆绑的筛查、评估、检测（SET）和监测策略，减少了面对面的就诊次数，然后通过患者、外展工作人员和临床医生之间的远程医疗沟通。仅在基线时进行美沙酮诱导和静脉采血以及 HCV 治疗 12 周后的静脉采血时才进行面对面就诊，以测量持续病毒学应答（SVR）。患者会收到外展工作人员和临床医生发来的支持性短信/电话。
总体而言，66 名正在积极注射吸毒的 PWID 均患有 OUD，接受了捆绑式实验室筛查；其中 35 人患有慢性 HCV 感染。参与者的平均年龄为 40 岁（均值），大多数为白人（N=18）男性（N=28），12 人住房不稳定。有 2 人失访，2 人入狱，留下 31 人开始使用泛基因型直接作用抗病毒药物（DAAs）。从转诊到首次静脉采血和开始使用 DAAs 的平均时间分别为 6.9 天和 9.9 天。另有 14 名患者新开始使用丁丙诺啡，6 名患者开始使用美沙酮；分别有 3 人和 4 人在基线时正在接受治疗。总体而言，开始使用 DAAs 的 29 名（93.5%）PWID 实现了 SVR；在住房不稳定的人群中，SVR 为 83.3%。
针对 COVID-19，SSP 为 PWID 制定了一种创新性的差异化护理模式，采用以患者为中心的方法，成功地对 HCV、HIV 和 OUD 进行联合治疗，减少了对患者的治疗需求，但同时支持持续获得循证治疗。
