Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE)

项目摘要/摘要 在新英格兰北部的农村州，阿片使用障碍(OUD)的流行及其相关后遗症 ？吸毒过量、艾滋病毒、丙型肝炎病毒(丙型肝炎病毒)、性传播感染(STI)和其他传染病 合并症？这是几十年来公共卫生和卫生保健面临的最大挑战。这两个人- 阶段，混合方法研究将检查注射吸毒者的流行病学、其感染后果和服务 缅因州15个农村县注射毒品年轻人的可及性(PWID)(UG3阶段) 汉普郡和佛蒙特州，然后实施综合远程医疗方法来治疗和减少 艾滋病毒、丙型肝炎病毒、性传播感染、主要细菌感染(例如感染性心内膜炎、感染性关节炎、骨髓炎、硬膜外 脓肿)和过量用药(UH3期)。UG3阶段将采用定性、定量、社交网络， 地理空间和实验室方法，以表征OUD的风险环境和流行病学 应答者驱动的感染性并发症、阿片类药物过量、危险行为、服务使用和需求 这些农村县360名青壮年PWID样本。对政策和环境的环境评估 基础设施将检查可用的服务、需求和差距。这一阶段还将建立收集 并运送标本进行集中的丙型肝炎病毒传播调查和分子流行病学分析。 在UH3阶段，一项混合类型1实施研究将评估区域化、 为农村残疾人提供扩大服务的综合模式。使用阶梯形楔形设计，UH3研究 将在这15个新农村地区的初级保健诊所和诊所(PCCP)推出扩展服务 英格兰各县使用区域实时远程会诊、评估和分流艾滋病毒、肝炎和OUD； 以及围绕关键主题(例如，预防过量用药和艾滋病毒)举行的由专家推动的双周虚拟案例会议 暴露前预防[PrEP])。在干预县UG3阶段招募的PWID将被 重新联系并提到了这些PCCP网站。主要结果将是PWID的比例：(1) 在初级保健计划现场的初步评估(“收容”)；(2)首次就诊的人在30岁内开始任何治疗服务 入会天数(“入会”)；(3)入会人员在入会后180天内获得3项以上服务(“入会”)； 以及(4)通过远程医疗讨论和跟踪(“保留”)。流程评估将评估障碍， 辅导员，implementationproblemsandnecessaryadaptations.Secondaryoutcomesincludetheproportion 接受甲型肝炎/乙肝疫苗接种和性传播感染检测；纳洛酮救援包；以及人类免疫缺陷病毒、艾滋病毒和丙型肝炎 治疗，包括在接受服务的人中抑制艾滋病毒和持续的丙型肝炎反应(SVR)。 该项目对RFA-DA-17-014做出了独特的响应，因为它将提供对高 使农村PWID面临风险，为社区应对战略提供信息，并实施全面、综合的方法 为了治疗OUD，减少美国农村PWID的过量用药和感染性并发症。

PROJECT SUMMARY/ABSTRACT In New England’s rural northern states, the epidemic of opioid use disorder (OUD) and its related sequelae ? overdose, HIV, hepatitis C virus (HCV), sexually transmitted infections (STIs) and other infectious comorbidities ? present the most substantial challenges to public health and health care in decades. This two- stage, mixed-methods study will examine the epidemiology of IDU, its infectious consequences, and service accessibility among young persons who inject drugs (PWID) (UG3 phase) in 15 rural counties in Maine, New Hampshire and Vermont, and then implement an integrated telemedicine approach to treat OUD and reduce HIV, HCV, STIs, major bacterial infections (e.g. infective endocarditis, septic arthritis, osteomyelitis, epidural abscess) and overdose (UH3 phase). The UG3 phase will employ qualitative, quantitative, social network, geospatial, and laboratory methods to characterize the risk environment and epidemiology of OUD, its infectious complications, opioid overdose, risk behaviors, service use and needs in a respondent-driven sample (n=360) of young PWID in these rural counties. An environmental assessment of policy and infrastructure will examine available services, needs and gaps. This phase will also build capacity to collect and deliver specimens for centralized HCV transmission investigation and molecular epidemiologic analysis. In the UH3 phase, a Hybrid Type 1 implementation study will evaluate the effectiveness of a regionalized, integrated model of expanded service delivery for rural PWID. Using a stepped wedge design, the UH3 study will roll-out expanded services into primary care clinics and practices (PCCP) in these 15 rural northern New England counties using regional real-time tele-consultation, assessment and triage for HIV, hepatitis and OUD; and virtual, expert-facilitated bi-weekly case conferences around key topics (e.g., overdose prevention and HIV pre-exposure prophylaxis [PrEP]). PWID recruited during the UG3 phase in intervention counties will be recontacted and referred to these PCCP sites. Primary outcomes will be the proportion of PWID: (1) with an initial assessment at a PCCP site ("intake"); (2) with an initial visit who initiated any treatment service within 30 days ("initiation”); (3) who initiated then received 3 more services within 180 days of initiation ("engagement”); and (4) discussed and followed via telemedicine (“retention”). Process evaluation will assess barriers, facilitators,implementationproblemsandnecessaryadaptations.Secondaryoutcomesincludetheproportion of PWID who receive: HAV/HBV vaccination and STI testing; naloxone rescue kits; and OUD, HIV and HCV treatment, including HIV suppression and sustained HCV response (SVR) among those who receive services. This project is uniquely responsive to RFA-DA-17-014 in that it will provide in-depth understanding of high- risk rural PWID, inform community response strategies, and implement a comprehensive, integrated approach to treat OUD, reduce overdose and infectious complications among PWID in the rural US.