Project Summary/Abstract Despite the more than decades long downward trend in HIV incidence among people who inject drugs (PWID), there is cause for alarm due to the COVID-19 pandemic and the instability the response will likely cause, particularly among vulnerable populations. COVID-19 will disrupt access to the very interventions that led to declining HIV incidence among PWID, including harm reduction services and antiretroviral therapy (ART). As a result, COVID-19 threatens to undo efforts to end the HIV epidemic in the US. Several recent HIV outbreaks in the US that resulted from increasing use and exposure to synthetic opioids highlights how the COVID-19 pandemic is being layered onto an existing public health emergency in the US that is disproportionately affecting PWID populations. It is unknown how the intersection of the opioid crisis and COVID-19 pandemic will interact to impact the health of PWID in the short term and whether it will create conditions sufficient to destabilize PWID populations enough to support the resurgence of HIV. Research is therefore urgently needed to examine the immediate impact and downstream consequences of COVID-19 on PWID. The objective of this proposal is therefore to determine the potential of HIV resurgence among PWID due to the impact of the COVID-19 pandemic on individual and network factors. Our central hypothesis is that COVID-19 will increase individual and social network instability sufficiently to promote HIV outbreaks among PWID populations. We propose the following three specific aims: 1) To examine threats to psychosocial, economic and behavioral stability and HIV control among an existing cohort of PWID during the COVID-19 pandemic; 2) To understand social and drug-use network stability during and following the COVID-19 pandemic; and 3) To estimate the potential for HIV resurgence among PWID as a result of the COVID-19 pandemic. To achieve these aims, we will leverage ongoing behavioral, laboratory and clinical data collection within the AIDS Linked to the IntraVenous Experience (ALIVE) cohort and collect new longitudinal social network data and qualitative data to characterize the disruption due to COVID-19. Importantly, we will advance our understanding of how individual substance use, HIV-related risk behaviors, and social network characteristics have changed as a result of COVID-19, relationships that are entirely uncharacterized. The evidence generated from this proposed research will inform the ongoing design of interventions targeted to PWID, not only to prevent emerging HIV outbreaks, but to support efforts to improve the health of PWID in the context of disruptions to care and services. Given that the COVID-19 pandemic will likely have prolonged impacts on PWID due to continued SARS-CoV-2 transmission in urban areas and continual cycling of non-pharmaceutical interventions (NPIs) until more effective prevention and treatment strategies are available, the research proposed here will have immediate and substantial impact on practice.

Project narrative This research is relevant to public health because understanding how the initial wave of the COVID-19 pandemic affected people who inject drugs will inform HIV prevention efforts and other interventions to mitigate ongoing and downstream negative health consequences for people who use drugs. This research is in line with NIDA HIV research priority to increase understanding of etiology, pathogenesis, spread, and persistence of HIV among people who use drugs and is responsive to PAR-20-036 with an explicit focus on understanding HIV disease dynamics with the goal of ending HIV in the context of the COVID-19 pandemic.