ISSUE: Since the onset of COVID19, Canada has experienced an unprecedented number of accidental drug toxicity deaths. Injectable opioid agonist therapy (iOAT) is a promising treatment option for people who use drugs (PWUD) that provides prescription grade opioids as a replacement to an increasingly toxic street supply. Scaling up iOAT services may help to circumvent the devastating impact that dual public health emergencies have had on PWUD.

DESCRIPTION: The Dr. Peter Centre (DPC) is the first community agency in North America to implement iOAT services. DPC has been tracking lessons learned and mobilizing knowledge gained to expedite the efforts of organizations in the early stages of iOAT implementation. There are particular considerations for community agencies implementing iOAT services that include establishing strategic partnerships and developing policies and practices that meet regulatory requirements.

LESSONS LEARNED: To mobilize the spread of iOAT services across Canada, this presentation will share findings from a process evaluation of the implementation of iOAT within a community agency setting. It will discuss key learnings for community agencies seeking guidance on the implementation of iOAT services, including opportunities for funding, sourcing medications, addressing iOAT prescriber shortages, establishing partnerships with local pharmacy teams, and navigating complex regulatory requirements.

RECOMMENDATIONS: iOAT is an effective treatment option that reduces the risk of overdose and HIV transmission for PWUD. With the unprecedented and relentless rise in overdose deaths exacerbated by COVID19, there is a need for the rapid implementation of iOAT services in diverse community settings. By sharing key learnings, this presentation aims to expedite the start-up and roll out of iOAT services for community agencies across Canada, contributing to a decrease in overdose deaths.

Background: The opioid overdose crisis continues to claim 1000s of lives each year in Canada. Safer supply programs (SSPs) provide individuals who use illicit opioids with an 'off label' prescription for pharmaceutical grade options. These innovative programs are being piloted across Canada. We examined SSPs delivered in urban community health centres using a primary care model.
Methods: We conducted semi-structured interviews with purposively recruited health and human service providers working in, and providing complementary services to, four SSPs in Ontario, from February to October 2021. Interviews examined SSPs implementation, challenges, and impact. Participants also completed a short questionnaire with demographic, training, and employment history information. Thematic analysis was conducted in MAXQDA and descriptive statistics in SPSSv28.
Results: We interviewed n=27 participants (physicians, nurses, community health workers, pharmacists). The programs prioritized clients refractory to opioid agonist treatment, living with unmanaged HIV/HCV, homeless, and palliative, and at disproportionate risk of fatal overdose. Participants described SSPs as a tool to engage some of the most marginalized people who use drugs. The primary care model enabled non-infectious disease experts to engage clients through a safer and reliable source of opioids and to build trust towards initiating HIV and/or HCV testing and treatment, and keep them engaged in care to achieve viral suppression and/or clearance, address longstanding health and mental health issues, and facilitate access to social supports (e.g., housing). However, providers struggled to keep up with the demand for enrolment, had limited options to offset ongoing illicit fentanyl use, and faced complex ethical decisions related to intake, dosage, and discharge. While beneficial, the primary care model limits program reach and creates conditions of burnout for prescribers.
Conclusions: SSPs are a promising component of the HIV/HCV continuum of care. However, our results indicate a need to expand access and pursue additional clinical and policy options.

Background: London, Ontario experienced a severe HIV outbreak amongst PWID in 2015-2016 despite widespread distribution of sterile injection drug use equipment (IDU-E). Investigations demonstrated that use of hydromorphone-controlled release encouraged sharing of “washes” and also preserved HIV viability within the shared IDU-E.
Methods: In 2016 a multidisciplinary team was brought together representing the local public health unit, AIDS Service organization, Housing services, indigenous groups, Addiction specialists, HIV care providers, a local health center and the city academic hospital-based HIV Clinic. In addition to ongoing contact tracing new Interventions included 1) A comprehensive program involving team based care which involved regular meetings to discuss cases focusing on establishment of housing and linkage to services 2) A “cook-your drug” campaign to educate PWID to heat “washes” with a cigarette lighter until bubbling (including providing free cigarette lighters with needle distribution kits 3) An educational campaign for physicians to reduce prescribing of long acting hydromorphone (and substitute immediate release preparations) 4) A health unit sponsored outreach campaign to assist patients to attend HIV clinic appointments. 5) Linkage to housing services 6) A supervised overdose prevention site was opened in Feb 2018.
Review of regional annual HIV Incidence between 2006-2021.
Results A rapid rise in HIV incidence was demonstrated in London-Middlesex with incidence rising to be significantly above that in Ontario in 2015 and 2016 with 75% of cases being in PWID. With institution of the comprehensive program, HIV incidence rapidly declined in 2017 to no longer be different than province wide rates and the fall was sustained through 2021 (Fig1).
Discussion/Conclusions: A comprehensive program involving multiple agencies and team-based care, along with community interventions to support “Cook your drugs”, reduce Hydromorphone-controlled release prescribing, and institute patient outreach- led to a reduction in HIV incidence which has been sustained over 5 years.

Background: People living with HIV (PLWH) who use drugs are hospitalized at higher rates than the general population and report receiving poor care. There is little discussion in the research literature that articulates how “knowledge” of healthcare providers is applied to the delivery of care for this population. Objective: Apply structuration theory to examine the perspective and actions of healthcare providers that create and re-create the structures (i.e., rules and practices) a patient is continually responding to or resisting. These factors positively and negatively influence the hospital admission of PLWH who use drugs. Methods: Semi-structured interviews were conducted with healthcare providers on in-patient hospital units in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed verbatim. Structuration theory was used to guide thematic analysis. Results: Twenty-six healthcare providers participated (physicians, nurses, dietician, pharmacists, and social workers). Core to the healthcare providers’ practical knowledge, knowledge articulated in acts and not always discursively expressed, are providers’ beliefs and professional lived-experience; practical knowledge often informs what healthcare providers believed was an objective understanding of the medical needs and life experience of PLWH who use drugs and also the implicit rules that were applied in their practice. Experience, specifically the professional lived-experience of interacting with patients who use drugs, was acknowledged as directing their clinical practice and decision making when delivering care to PLWH who use drugs. At times, this professional lived-experience-informed understanding superseded research findings or evidence within the relevant literature. Conclusion: The practical knowledge of healthcare providers often guides delivery of healthcare for PLWH who use drugs. Engaging in reflexive monitoring (e.g., taking part in a research interview) can shift practical knowledge to the discursive level. Analysis of discursive knowledge produces opportunities to influence the actions of healthcare providers, thereby impacting the hospital admission experience of PLWH who used drugs.

Background
Safer opioid supply (SOS) programs – where clients are prescribed pharmaceutical opioids (generally hydromorphone tablets) and provided comprehensive health/social supports – are a novel yet controversial intervention to reduce health risks associated with the unregulated drug supply. London Intercommunity Health Centre (LIHC) developed Canada’s first SOS program in 2016.

Methods
We conducted a population-based matched cohort study of London, Ontario residents diagnosed with opioid use disorder (OUD) between January 1, 2016 and March 31, 2019. All LIHC SOS clients who entered the program during the study period and who could be linked to ICES data were matched on demographic and clinical characteristics to London residents with OUD unexposed to the program. Primary outcomes were emergency department (ED) visits, hospitalizations, hospitalizations for infections, and total healthcare costs (excluding primary-care). We compared rates of each outcome in the year preceding and following index and used ARIMA models to evaluate impacts of SOS program initiation.

Results
Compared to the matched unexposed group, SOS clients were more likely to have HIV (34.1% vs. 7.6%; STD 0.69), hepatitis C (69.5% vs. 25.3%; STD 0.99), and hospitalizations for substance use disorder (18.3% vs. 9.5%; STD 0.26) and skin/soft tissue infections (18.3% vs. <6.1%; STD >0.10) at cohort entry. In the year following cohort entry, rates of ED visits (3.09 vs. 2.12 per person-year; p<0.001), inpatient hospitalizations (0.91 vs. 0.42 per person-year; p<0.001), hospitalizations for incident infections (0.32 vs. 0.16 per person-year; p=0.03), and healthcare costs ($15,287 vs. $7,237 per capita; p=0.001) declined significantly among SOS clients. Among unexposed individuals, no change in primary outcomes were observed.

Conclusion
While continuing research on SOS programs is necessary, the significant decline in hospitalizations among SOS clients alongside the lack of increase in infections, opioid-related deaths or all-cause mortality provides reassuring initial data on the safety of SOS programs.

Background: In Canada, women living with HIV (WLWH) continue to face many barriers to accessing health care services, alongside other social and structural inequities. This mixed methods study assessed the experiences accessing health care services among WLWH in the context of COVID-19.

Methods: We drew on a COVID-19-specific quantitative survey with 166 cis and trans WLWH (April/2020-August/2021) as part of the SHAWNA Project, an open longitudinal community-based research study with WLWH in Metro Vancouver. We conducted 28 semi-structured interviews with a subset of WLWH in SHAWNA (May/2020-July/2020). This research was guided by a socio-ecological framework to understand the experiences of WLWH accessing health care during the COVID-19 pandemic.

Results: Among 166 women, with 6.0% identifying as trans, 53.0% were Indigenous, 35.5% were White, and 10.2% were Black and/or otherwise racialized. Overall, 45.2% of participants reported increased difficulty accessing routine healthcare since COVID-19 began, and 28.3% reported increased difficulty accessing HIV care. Overall, 10.8% reported difficulties accessing antiretroviral therapy (ART), while 15.1% reported increased access to ART. In qualitative interviews, some women described that the shift to remote/virtual care and appointments was convenient and alleviated fear of exposure to COVID-19, while others described negative impacts on confidentiality and establishing rapport with providers. Further, the shift to remote/virtual care had a substantial impact on continuity of care/interprofessional care (e.g. HIV-related blood work, mammograms), resulting in delays in accessing services. Drug use stigma and discrimination, a common barrier to accessing pain medications, was exacerbated for some participants. This was further complicated by the shift to remote/virtual care preventing physical exams.

Conclusion: Our findings indicate challenges and opportunities in the context of many health services providers continuing to provide remote/virtual care and limit in-person services. Our study highlights the importance of trauma-informed health services with WLWH in all care environments to support health access.