State Spotlight Series: Syndemic Approaches to Substance Use and Infectious Disease

Governors and their teams are responding to a rapid rise in syphilis and congenital syphilis cases. The National Governors Association Center for Best Practices (NGA Center) is working to support states and territories in implementing a "syndemic" approach to this and other infectious diseases, recognizing that these outbreaks are intertwined with substance use. A syndemic refers to intersecting epidemics that are not only concurrent or sequential, but also have synergistic relationship, with overlapping or interactive risk factors, and often a context of shared social and behavioral risk factors and healthcare access gaps.

The NGA Center supported four states (Nevada, Massachusetts, Rhode Island, and Utah) through a learning collaborative focused on responses to the intersecting epidemics of substance use and infectious diseases, including syphilis, HIV, and HCV. The learning collaborative, Strategies to Address the Infectious Disease Consequences of the Opioid Crisis through a Syndemic Approach, kicked off in December 2023 with informational presentations and state action planning. In addition to presentations about syndemic causes, epidemiology, and policy strategies, state teams heard from Dr. Meghan Curry O'Connell, Chief Public Health Officer of the Great Plains Tribal Leaders Health Board. Dr. O'Connell spoke specifically to the disproportionate rates of syphilis and congenital syphilis among American Indians and Alaskan Natives, as well as strategies for states to support tribal governments in their response efforts.

Each project was state-led and defined by the teams' focus area, within the context of the syndemic of substance use and infectious disease. State teams documented numerous successes throughout the six-month learning collaborative:

Massachusetts

Expanding Infectious Disease Testing Services in Opioid Treatment Programs Across Massachusetts

Infectious diseases such as Hepatitis C (HCV), HIV, and sexually transmitted infections (STIs) are prevalent among patients accessing Opioid Treatment Program (OTP) services; however, limited screening and treatment is conducted in these settings. Injection drug use (a primary route by which opioids are ingested) increases risk for infection with HCV and HIV. Additionally, drug use is associated with sexual behaviors that increase risk for STIs, including transactional sex. OTPs provide access to medications for opioid use disorder (MOUD) like methadone and buprenorphine but are often siloed from other forms of healthcare. It is estimated that a significant portion of those who seek treatment in OTP settings have state Medicaid (MassHealth) coverage. Limited infectious disease testing is conducted by OTPs due to multiple operational challenges with billing, provider capacity, and workflow in these settings, despite MassHealth coverage of eligible OTP patients. Opportunities exist to ensure that patients are tested and treated for infections that are prevalent among people with current or past drug use. OTPs provide an opportunity to engage, test, and treat this population and to support their linkage to care and adherence to infectious disease treatment.

Massachusetts leveraged the NGA Syndemic Policy Academy to increase OTP clinician knowledge of infectious disease testing opportunities and resources, and to promote integration of HIV, HCV, and STI testing in OTPs. State team members representing the Department of Public Health (DPH) and MassHealth collaboratively developed a best practice document for infectious disease testing in OTPs. The team's project goals were:

• Promote opportunities to provide infectious disease testing to MassHealth beneficiaries accessing care in OTPs.
• Clarify MassHealth scope of coverage for clinically indicated infectious disease testing (HIV/HCV/syphilis) in OTPs for eligible enrollees; and improve general OTP staff knowledge of the importance of testing for patients who are MassHealth beneficiaries.
• Produce best practice document for OTPs on infectious disease testing for OTP patients who are MassHealth beneficiaries, guidance to integrate infectious disease testing in OTP settings, and reference to billing information to optimize reimbursement and sustainability of testing interventions.
• Inform OTP providers of resources available in Massachusetts to make referrals when a patient receives a positive test result or needs access to infectious disease services.
• Increase access to infectious disease testing in OTPs and improve timely diagnoses and linkage to care and treatment for individuals with opioid use disorder receiving care in OTP settings.

The team developed a best practice memo for OTPs which was discussed during a listening session with OTP providers. The memo serves as both a recommendation from senior leaders to implement infectious disease testing in OTPs, as well as a detailed guidance document to accomplish this integration operationally. The team used the listening session to review the memo's content, provide examples of OTP sites already providing infectious disease testing, solicit feedback to strengthen guidance in the memo, and answer questions. The team will release the memo publicly in the summer of 2024 with support from the Department of Public Health Commissioner and MassHealth leadership. Additionally, a newly state-funded OTP training and technical assistance service will host the best practice memo, offer academic detailing, and clinical quality improvement support to providers throughout the state.

The varied nature of OTPs across the state is a challenge, given differing levels of personnel (e.g., clinical and non-clinical staff), staff capacity, experience with infectious disease testing, and resources to implement infectious disease testing on site. State team members also face the challenge of determining how best to evaluate the success of implementation (at the individual OTP and/or OTP system level), and how to determine whether infectious disease testing and treatment/referral to treatment has increased as a result. This project required involvement of a wide group of individuals across state agencies, who convened during a compressed timeline, amidst an environment of contracting fiscal resources. The Massachusetts team plans to continue building out the new OTP Training and Technical Assistance resource and engaging with OTPs to implement the infectious disease testing practices detailed in the guidance document. They will continue to improve training on infectious disease topics for the OTP workforce. The team also plans to work with MassHealth to further examine opportunities and impacts of making certain billable health services at OTPs and other SUD treatment settings available on site. These efforts will advance a longer-term vision to expand available and billable healthcare services in OTPs beyond infectious disease testing, including biomedical prevention and treatment for infectious diseases, in ways that will improve health outcomes at the individual and population level.

Nevada

Building a Syndemic Response Infrastructure in Nevada

The State of Nevada has been experiencing concurrent increases in opioid-related emergency department visits and overdoses, as well as increases in infectious diseases, including HIV, syphilis, gonorrhea, and chlamydia. Prior to the National Governors Association (NGA) Syndemic Learning Collaborative, there was no formal statewide syndemic response to address these intersecting health conditions.

To address the increasing rates of overdose and infectious disease through the NGA learning collaborative, the State of Nevada convened state team members (Nevada state team) from the Governor's Office, the Nevada Department of Health and Human Services, and Roseman University.

The following goals were identified as part of the learning collaborative:

• Create a formal inter-agency and community driven, collaborative syndemic workgroup to focus on the intersection of opioid use, HIV, and Sexually Transmitted Infections (STIs.)
• Enhance and overlay surveillance and data collection for opioid use, HIV, and STIs.
• Facilitate a comprehensive evaluation of harm reduction services throughout Nevada to identify gaps and opportunities.
• Utilize findings from the harm reduction evaluation to drive upstream policy recommendations that could help prevent new infections of HIV and STIs.
• Develop strategies to increase testing, linkage to care, and access to treatment.

The Nevada state team was committed to advancing the goals of the learning collaborative and engaged partners from around the state to participate in the workgroup. Recognizing that staff bandwidth was limited, the Nevada team successfully advocated to leverage opioid settlement funding to support the hiring of a medical epidemiologist, whose position will be focused on advancing Nevada's syndemic workgroup. The medical epidemiologist is expected to be onboarded in July 2024.

The state team also began recruiting members for the syndemic workgroup. Participants will include:

• State of Nevada Department of Health and Human Services Office of State Epidemiology
• State of Nevada Department of Health and Human Services Office of HIV
• State of Nevada Department of Health and Human Services Bureau of Health, Wellness and Prevention
• Southern Nevada Health District
• Northern Nevada Public Health Department
• Roseman University

Additional successes include participants of the EMPOWERED program (a Nevada-based program that supports pregnant and postpartum individuals who use or have used opioids or stimulants) participated in two listening sessions with the Southern Nevada Health District to assist with the development of an awareness campaign for syphilis treatment and prevention.

The Nevada state team experienced challenges with capacity, as several team members departed for other positions or promotions. Additional considerations for the team were around better understanding the time commitment to establish an inter-agency learning collaborative. The Nevada state team looks forward to continuing forward with their identified goals over the next few months. With the onboarding of the new medical epidemiologist, who will be tasked with managing the state's syndemic work, there will be more capacity to launch the workgroup and operationalize its goals.

Rhode Island

Innovative Approaches to Address the Infectious Disease Consequences of Opioid Use in Rhode Island

Like many states, Rhode Island has recently seen increases in congenital syphilis cases. The state identified a need to strengthen screening and treatment in prenatal care and address prenatal care access barriers for people who use drugs-barriers that include housing instability, substance use, concerns about DCYF involvement, and past and/or anticipated experiences of stigma, discrimination, and shame in health care.

Rhode Island has made significant investments and has long-standing initiatives in the areas of overdose prevention, drug user health, maternal and child health, and infectious disease prevention. The state team leveraged the NGA Syndemic Learning Collaborative as an opportunity to align and coordinate ongoing work across agencies and teams, ensuring teams were working towards the same goals, identifying opportunities to partner, and sharing information about ongoing and planned work. Alignment of overdose prevention and infectious disease screening and treatment was identified as a key priority in working towards a "whole person" approach.

Led by the Governor's Overdose Prevention Task Force, the cross-agency team further strengthened and springboarded their work from the existing syndemic infrastructure in the state. The team brought together leadership from the Office of HIV, STD, TB, and HIV Prevention; the Substance Exposed Newborn Program; the Department of Behavioral Healthcare, Development Disabilities & Hospitals; the Opioid Settlement Advisory Committee; and a community-based organization partner.

As part of their participation in the learning collaborative, the team sought to focus on several areas to align work across agencies and teams. Rhode Island has a robust harm reduction and recovery infrastructure, with recovery centers, mobile outreach, harm reduction vending machines, HIV and HCV rapid testing, and home delivery of risk reduction supplies. The team worked to strengthen and expand an action plan for a syndemic approach that brings in infectious disease, maternal and child health, and overdose prevention. They also focused on expanding drug user health services, with a focus on collaboration and coordination opportunities in street-based outreach and wound care, harm reduction vending machines, and other areas. This collaboration is accelerating the integration of MCH services into harm reduction and drug user health services as part of the team's work in the learning collaborative-in practice this included the distribution of pregnancy tests and referral to prenatal care as part of street outreach, and pregnancy test distribution through harm reduction vending machines, among other actions. The team has seen significant successes in these focus areas prior to and during their participation in the learning collaborative. The state engaged with the community to develop congenital syphilis prevention messaging, gathering and incorporating feedback to create and launch a new campaign - Healthy Beginning - using positive rather than fear-based messaging to encourage pregnant individuals to access prenatal care. Looking forward, the team will continue their collaboration to ensure forward momentum of these activities by expanding harm reduction vending machines in high traffic public areas, reproductive health street outreach, and the Healthy Beginning campaign.

Utah

Removing Syndemic Treatment Access Barriers for Opioid Use Disorder and Hepatitis C Virus in Utah's Prisons

Utah's participation in the NGA Syndemic Learning Collaborative focused primarily on the state prison system, in which few people with opioid use disorder (OUD) and hepatitis C (HCV) were receiving treatment. Initially, only pregnant persons, those experiencing acute withdrawal upon entry, and those being released were receiving medications for opioid use disorder (MOUD). HCV treatment was limited to those at highest risk for hepatic fibrosis and cirrhosis based on AST to platelet ratio index (APRI) and fibrosis (F) scores. A recent restructuring moved the Division of Correctional Health Services under the Utah Department of Health and Human Services, and SB212 in 2024 allowed for the continuation of medications for opioid use disorder (MOUD) treatment for incarcerated people upon intake.

While navigating these changes, the state joined the NGA Syndemic Learning Collaborative with the goals of increasing access to HCV treatment and MOUD, improving treatment outcomes, enhancing related surveillance and data collection, and implementing new harm reduction measures. To improve MOUD access, the state hired an addiction medicine specialist, began continuing MOUD at intake for those coming in on active prescriptions, and transferred grant funds to Correctional Health Services. They also developed a peer support specialist certification for incarcerated individuals, worked to build community partners, and collaborated on training.

As a result of these efforts, Utah's prisons have seen a 233% increase in MOUD access. HCV efforts have also paid off, with a 32% increase in access to HCV treatment, which is no longer limited to those with high fibrosis scores. As part of these efforts, HCV evaluation and patient education forms have been standardized and incorporated into the EHR. Utah is also piloting "Keep On Person" (KOP) for individuals prescribed HCV treatment medications, with success. The state has established baseline measures for HCV screening and treatment, is exploring various cost options for HCV testing and treatment, has applied for and continues to seek funding opportunities to support this work. Beyond HCV and MOUD access improvements, the state also cites the success of bringing together this cross-department, multi-disciplinary group to problem-solve and collaborate.

These successes have not been without challenges. Workforce insufficiencies continue to be a barrier, especially amid the recent restructuring, and EHR systems are often different across systems and insufficient. Funding constraints remain a challenge, given the high cost of these medications. The state faced a major hurdle to expanding MOUD when medication supply was disrupted as a result of blind wholesaler thresholds, a recurring issue nationally that SAMHSA has explored in town halls and published about in recent reports.

Despite challenges, the team is committed to continuing to work together and identifying opportunities to expand MOUD and HCV treatment access. Demonstration of cost savings will be a critical part of scaling these strategies and moving these efforts forward.

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