People living with HIV and particularly those who are not virally suppressed, were considered to be at heightened risk for COVID-19 serious consequences because of being immuno compromised and experiencing high prevalence of comorbidities . Among such individuals are people who use drugs and those with mental health problems . Therefore, understanding patterns of who did not obtain COVID-19 testing among PWUD and PLWH provides insight into how those with intersectional challenges may have experienced systematic exclusion from public health initiatives during the COVID-19 pandemic. This may shed light on strategies that may help us enhance access to testing among marginalized populations who experience health inequities in a future public health crisis. To assess the impact of the COVID-19 pandemic among those confronting multiple challenges such as substance use and HIV, a consortium of NIDA funded cohorts entitled the Collaborating Consortium of Cohorts Producing NIDA Opportunities launched a specially designed survey administered three times during the pandemic. The C3PNO COVID-19 survey module contained specific measures for PWUD and PLWH. These data provide insight into the compelling questions of change in the levels of substance use among those enrolled in the cohorts many of whom have been using long term, been in substance use treatment, and have heavy use . Moreover, the results may demonstrate the extent to which critical COVID-19 public health interventions such as testing for the virus reached PWUD and PLWH. The C3PNO consortium was uniquely positioned to identify impacts of the COVID-19 pandemic on PWUD and PLWH as its cohorts following large numbers of such individuals across North America. The analyses described herein focus on the prevalence and factors associated with COVID-19 testing among PWUD and PLWH who participated in the first two rounds of the C3PNO COVID-19 module.
C3PNO was established in 2017 by the National Institute on Drug Abuse to enhance data sharing opportunities and mechanisms to facilitate collaborative research efforts among NIDA-supported cohorts that examine HIV/AIDS in the context of substance misuse. Details of the participating cohorts and other methodology have been previously described but in sum,cannabis grow indoor the C3PNO consortium is comprised of nine NIDA cohorts located in major cities throughout North America with a combined sample size of up to 12,000 active participants. Some cohorts had initial enrollment criteria that participants be people who inject drugs while other cohorts are young men who have sex with men. The consortium links a wide range of behavioral, clinical, and biological data from diverse individuals at high-risk for HIV or living with HIV participating in the cohorts. Starting in May 2020, the consortium launched a survey to examine patterns of substance use, substance use disorder treatment, and utilization of HIV prevention and care services in the midst of the COVID-19 pandemic. Specific domains collected as part of the survey included overall impact of the COVID-19 pandemic and related governmental/societal restrictions on day-to-day life, adoption of COVID-19 prevention practices, COVID-19 testing and symptomatology, changes in substance use behaviors as well as reports of pandemic impact on access, quality, and pricing of illicit substances. The survey also included various measures of mental health including anxiety as well as access to medical care and substance use treatment. At the time of this study COVID-19 testing was available and recommended mostly for those with symptoms defined by the CDC at the time as the most predictive of COVID-19 infection including: fever, feeling feverish, chills, repeated shaking with chills, muscle aches or pain, runny nose, sore throat, new or worsening cough, shortness of breath, nausea or vomiting, headache, abdominal pain, diarrhea, and sudden loss of taste or smell.
In the survey module current symptom reports were collected. Eight of the nine C3PNO cohorts participated in both of the first rounds of data collection but one was unable to share its data – all nine cohorts joined for later rounds. Each participating cohort contacted a minimum of 200 of their cohort members to participate in the survey eligible if they:were previously enrolled in one of the eight participating C3PNO cohorts;participated in a recent study visit ;were English and/or Spanish speaking; and willing and able to complete the survey remotely. Cohort investigators were encouraged to enroll participants who had a recent history of substance use as determined by self-report at their most previous visit. The survey was either self-administered through a web based survey for participants that had computer and internet access or interviewer administered by telephone for those participants without online access. The survey took approximately 20 min to complete and participants were remunerated for their time. The study was approved by the institutional review boards of the consortium cohorts and each participant provided informed consent for their study participation. There were 4035 responses to the survey across all eight cohorts that participated in both of the first two rounds and collected fully analyzable data; 3762 were available for this analysis because the Canadian cohorts confronted restrictions with sending data and were not able to be included. The analyzed data for this manuscript includes data from 2331 individuals who completed one or both of the first two rounds of the C3PNO COVID-19 module. Participants were offered participation in each round of the survey regardless of participation in first round. This resulted in 1431from individuals responding to both rounds. The first round was conducted from May-November 2020 and the second round from October 2020 through April 2021.
Median time between surveys for participants who completed both rounds of the survey was 4.1 months . The time to implement the survey was a window period starting from when the programmed survey was made available for each round . Intervals are overlapping because some cohorts had not finished their first round when the first cohorts to implement started their second round. The survey was implemented in a very challenging time of research administration with entire components of universities shut down for months delaying aspects of survey conduct such as reviews of research and procedures for compensation. Therefore,vertical farming supplies the cohort research teams did the best they could to administer the survey when available and to reach the requested minimum number of participants and there was a range in time as to how long it took them to be able to collect data. Moreover, the implementation of the survey resulted in different time frames required by cohort research teams to complete the data collection. Those that sent links to web-based questionnaires and had participants who were responsive to these completed the rounds relatively quickly . Other cohorts had many older participants who had to be interviewed by telephone . These teams required much more time to reach participants and conduct the interviews. We implemented and conducted this research in a unique and challenging time in history that required some flexibility and innovations in data collection. This means because of the geographic range captured in these surveys, participants in different cities responded during different phases of the pandemic. Finally, given the burdens on the cohort staff to implement this study in addition to their other work, systematic data on refusal rates were not able to be collected. The main outcome variable for these analyses was COVID-19 testing and was assessed via self-report. Specifically, participants were asked if they were tested for COVID-19 and if yes, if they have ever tested positive.
Participants were also asked if they had symptoms of COVID-19. Participants were considered to have recent substance use if they reported using any of the following substances in the past month: methamphetamine, cocaine, heroin, fentanyl, or misused prescription opioids. Alcohol, tobacco, and cannabis use were also assessed but are not the focus of these analyses. Univariate analyses provided descriptive statistics for the sample overall and by COVID-19 testing status. Comparisons of demographics, substance use and frequency of use, as well as HIV-status by COVID-19 testing status were based on t-tests, chi-square methods, and other non-parametric tests as appropriate while adjusting for the effect of the subject . Factors associated with the outcome of interest were assessed using regression analysis with generalized estimating equations in order to account for the within-subject correlations. Overall the C3PNO COVID-19 module achieved a sample made up of half respondents from cohorts of those who had enrolled as people who inject drugs and half respondents from cohorts of young men who have sex with men. Among unique participants completing the survey , the median age was 39 years with more male and over half identifying as Black , 25 % Hispanic/Latino, and 13 % White/ Caucasian . Nearly half of respondents were living with HIV , 66 % reported being unemployed 5 % unstably housed, and over one third reported food insecurity. Substance use as defined by self-reported use of methamphetamine, cocaine, heroin, fentanyl, or misuse of prescription opioids in the past month was reported in 16 % of surveys.Among those reporting substance use, 23 %reported daily use, with the remainder using at least once, but less than daily in the preceding month. Overall 19.4 % of participants reported participation in treatment including those reporting receiving some treatment for substance use, participating in a 12-step program, or on methadone. Missing data regarding the 12 step program participation suggests a potential underestimate of those in treatment and may partially help to explain low reports of substance use. Substance use treatment and methadone was reported by individuals in 13.3 % of surveys which was very close to those reporting only methadone treatment. Moreover, among those who reported being in substance use treatment , 75 % reported no substance use in the past month, with others potentially using substances at a reduced rate. Of the 3762 responses, just under half reported being tested for COVID-19 . The majority reported nasal swab testing , with 19 %reporting an antibody blood test . Of 2331 individuals, 448reported having some kind of COVID-19 test at both surveys. Testing positive for COVID − 19was reported at 163 surveys . COVID-19 hospitalization was reported at 24 surveys that represents 6.0 % of all those who reported testing positive . Among those completing both rounds of the survey, in the first round 36.7 %reported ever testing for COVID and for the second round 52.7 %with 28 %reporting testing only in the second round. Finally, across surveys, among participants with current symptoms 41.5 % report having been tested and 58.5 % report having not been tested . As shown in Table 2 this represents 35 % of all those surveys completed with reports by those with symptoms of COVID-19 having been tested. Across study surveys, among PLWH fewer were tested than not tested . Among unemployed fewer reported testing and among those reporting drug use fewer tested than not tested . There was no difference by housing . Of key interest was substance use and a greater percentage of those who were not tested for COVID-19 reported substance use in the past month with differences noted by frequency of substance use . Specifically, while no differences in daily substance use was noted among COVID-19 testers and non-testers, the prevalence of intermittent substance use was higher among those who were not tested for COVID-19 . The prevalence of COVID-19 testing was significantly lower among those reporting heroin use and methamphetamine use and higher among those reporting Rx Opioid use than those not using these substances . When substance use frequency was examined within variables significantly associated with COVID testing , the fewest tested were those who were HIV positive and unemployed who reported using substances intermittently . Based on multi-variable analysis, after adjusting for age, sex, and cohort type the following were independently associated with COVID-19 testing: African American/Black identity had a reduced odds of COVID- 19 testing as compared to those who identified as Caucasian/White = 0.68; 95 % confidence interval0.53,0.87; those who were unemployed also had lower odds of testing and those who were HIV-positive. Substance use was not associated with COVID-19 testing in these models . Interactions between HIV status and substance use and unemployment by substance use were examined and found not significant. Table 5.