Hello, I am Dr. Andrew Saxon. On behalf of the American Psychiatric Association, welcome to today's webinar, HIV and Substance Use Disorder, Intertwined Epidemics. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. Next slide, please. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next. You'll reserve some time at the end of the presentation for Q&A. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. Next. Now I would like to introduce you to the faculty for today's webinar, Dr. Michael Polignano, principal instructor at Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences. Dr. Polignano is board certified in addiction medicine and specializes in the intersection of addiction and HIV psychiatry. I'm really looking forward to this presentation and learning a lot. Please take it away, Dr. Polignano. Great. Thank you so much, and hello, everyone. So as mentioned, I work both in the addiction medicine section at the Stanford Department of Psychiatry, and I also work as a psychiatrist at a county HIV clinic in San Jose, California. So I work directly with patients with HIV in a setting that provides integrated care where we have infectious disease physicians, psychiatrists, mental health providers, and social workers, and intensive case management. I have no financial relationships or conflicts of interest to report. The target audience, the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders generally. The educational objectives for today, at the conclusion of this activity, participants should be able to recognize the structural factors that perpetuate intersecting epidemics of HIV and substance use, apply to prevention approaches for HIV disease, implement treatment approaches and structural interventions that might reduce health disparities among people with co-occurring HIV and substance use disorders. Here's an overview of what I intend to talk about today. I'm going to start with a description of an outbreak of HIV in a rural community in Indiana as showing some of the facets of the structural factors that influence the connection between HIV and substance use. I'm going to talk a bit about the epidemiology of HIV as it overlaps with substance use disorders. I'm going to talk about the idea of syndemics as an organizing concept for thinking about the intersection of HIV and substance use. Then move on to screening and prevention, talking about syringe services programs as a very powerful method of preventing new infections among people who inject drugs, as well as PrEP, pre-exposure prophylaxis, as another very effective method of reducing new HIV infections. And then lastly, I'm going to talk about treatment, both medication-assisted treatment, an overview of that, and a brief overview of behavioral treatments, particularly targeted treatments for subpopulations at risk for HIV and substance use disorders. You may have heard about this, and it's been well covered in medical journals and in the popular press. In Scott County, Indiana, in 2014, a rural county, there was an unprecedented outbreak of HIV. It was for a rural community in the United States. In the preceding 10 years, fewer than five new HIV infections were reported in the county. But in November of 2014, a cluster of infections was detected, and by September of 2016, 205 people in this small town of about 4,400 folks were diagnosed with HIV. They were all, or many of them, were at risk because they were injecting the extended release form of oxymorphone, which was approved back in 2006 for the management of moderate to severe pain. By March 2015, then-Governor Mike Pence declared a public health emergency, allowing permission to start a temporary syringe services program. Also, what was done then was to expand access to HIV testing, treatment, and other services were put in place. A subsequent analysis of transmission networks and viral genetic data suggested that most of the new HIV infections had occurred actually prior to the declaration of a public health emergency. It was after this outbreak ended that Congress overturned a federal ban on using federal funds to support syringe services programs, which are programs that allow people to exchange contaminated injection equipment for sterile injection equipment, among other important services. Contact tracing after the Scott County outbreak showed a network of about 1,000 high-risk linkages among 411 individuals, including 183 who received a diagnosis of HIV infection during the outbreak investigation. Of these high-risk contacts, 79% were injection drug contacts only, 7.9% were sex partners only, 13% were sex partners and injection drug users. Subsequent to the outbreak, the CDC did an analysis of the number of HIV-infected individuals and the CDC did an analysis of county-level structural factors that may have led to vulnerability for an HIV outbreak in rural communities similar to Scott County. They identified 200 counties in 26 states within the 95th percentile of the most vulnerable counties. The factors that they found that correlated most strongly with risk for an HIV outbreak included the level of drug overdose deaths, the level of prescription opioid sales, the median per capita income, percent of unemployment in the population, ethnicity with white folks and non-Hispanic folks as a percentage of the population, and buprenorphine prescribing potential, looking at the number of waivers in particular areas per 1,000 people in the population. They used for this analysis acute HCV, hepatitis C infections as a proxy for IV drug use because there's no reliable or easy-to-get measure of county-level injection drug use, and HCV is very easily transmitted and therefore occurs not at the same rate as injection drug use, but the rates track each other, so they're tightly correlated. So, we see in their analysis that this community with high rate, these communities with rates of unemployment, low high school graduation rates, large numbers of prescription opioid sales, low per capita income, and where there was a predominantly white population with little buprenorphine prescribing or at very high risk for another HIV outbreak. So, this CDC analysis points to certain structural factors, independent of individual-level behavior, that influenced the risk for HIV in the setting of substance use. So, I'll talk a bit about the epidemiology of HIV in the United States. It remains primarily a disease among gay and bisexual men or men who have sex with men. There's two ways of categorizing men who have sex with men. The CDC reports it as gay and bisexual men, which is sexual orientation. It's how people identify. There are other reports of sexual behaviors, so that's called men who have sex with men, and that is just a description of sexual behavior among people who may not identify as gay or bisexual. Bottom line is that the vast majority of new diagnoses as of 2019 and throughout the epidemic of HIV remain among men who have sex with men. So, 69% in 2019, 23% of the new infections in 2019 were accounted for by heterosexual transmission, and only 7% were among people who inject drugs. So, despite recent increases in the number of people who inject drugs who are acquiring HIV, it still represents a very small percentage of the total number of new infections. So, you can see that over time there's been a tremendous reduction in the number of people who inject drugs who are acquiring HIV. Although injection drug use has been associated with HIV from the beginning, very effective public health interventions, mainly syringe services programs, have reduced the proportion of HIV transmission due to injection drug use from a peak of over 30% in the early 90s to less than 10% in recent years, and that has remained relatively stable. With these small increases, as you can see, starting in 2014 and up through 2019, we see the curve slightly changing, and that is driven by the opioid epidemic. There's no data for 2020 or 2021. My sense, given that there has been an increase in overdose deaths, is that there will be, and there's been a low uptake of syringe services programs, which were recommended following the CDC investigation, that there will be perhaps, there's a likelihood that there will be a further increase in the number of folks who are acquiring HIV through injection drug use. So the most affected populations are, in terms of ethnicity and race, remain Black or African American men who are having male-to-male sexual contact. In 2019, they made up, as you can see, the largest proportion of new infections, followed by Latino or Hispanic male-to-male sexual contact, and then White male-to-male sexual contact. And then among women having heterosexual contact, Black women made up the largest proportion of new infections. Black men, somewhat less than them, about half of that. Latinas, Hispanic women, also are at higher risk for infection through heterosexual contact. And then at the bottom, we have White women who are at risk through heterosexual contact. So you can see there, there's tremendous disparities on the basis of race and ethnicity in rates of new HIV diagnoses in the population. HIV is concentrated in certain geographic hot spots. Many of these are more urban areas, and some of them are rural areas that are identified with the blue shading. So most of the new diagnoses recently have been in only 48 counties, Washington, D.C., and San Juan in Puerto Rico. So among people who are living with HIV, multiple studies show between 50% to 80% have current or past histories of substance use disorders. That's an astonishingly high amount. In a national clinic sample of urban HIV treatment clinics, 48% of folks, of patients there met criteria for substance use disorder. Polysubstance use was common. Opioid use was really not that prevalent. What was prevalent was cannabis use, alcohol use, methamphetamine use, and cocaine use. There's not only a high rate of substance use among people who have HIV, but there's a high rate of substance use among some at-risk populations. In particular, men who have sex with men, generally speaking, have higher rates of binge drinking, higher rates of cocaine use, higher rates of methamphetamine use. For example, though, about only 0.6% of the U.S. population had used methamphetamine in the last 30 days. About 12% of men who have sex with men with HIV had done so. That's already 20 times higher than the general population. And in some studies, it's an older study, it shows about or suggested that about 30% of MSN who have acquired HIV did so in the context of methamphetamine use. So, in HIV care, there's the concept of the continuum of care, starting with a diagnosis, then going on to being enrolled into HIV care, then retained into care, and importantly, started on highly active antiretroviral therapy, maintained on that therapy, with the goal of suppressing the virus through the use of antiretrovirals. And people who have used drugs or have substance use disorders have reduced penetration at each level of the continuum of care. So they have delayed diagnosis, reduced entry into care, reduced retention, delayed initiation of antiretroviral therapy, and delayed use of antiretroviral therapy. And despite being on it, have inferior treatment outcomes, in part due to issues with adherence. Among MSM, who are the group with highest risk for HIV, there are significant disparities, as an earlier slide showed. Among Black and African-American men and Latino men, many fewer have made use of or been able to make use of a pre-exposure prophylaxis than among white or gay and bisexual men. And only about two in three Black men and Latino men have been able to make use of prophylaxis, whereas Latino men who are gay and bisexual or MSM with HIV had viral suppression compared with about 75% of white gay and bisexual men. So I wanted to talk briefly about this idea of syndemics as an organizing idea to explain the connection between HIV and substance use. It seems obvious that what leading substance use and HIV at the level of individual behavior is, for example, the sharing of contaminated injection equipment, or in the setting of non-injection substance use and sexual behavior, intoxication causes disinhibition, which leads to increased risk-taking acutely or chronically. Or chronic use of substances impairs executive function and inhibitory control, which also lead to an increased risk-taking and impaired ability to reason about consequences. So that seems pretty obvious, the connection there. But if we step back, we can ask further, why are people using drugs in the first place? Why are they sharing? If they are injecting, why are they sharing injection equipment? Why are they reusing contaminated equipment? And why are rates of substance use higher in some at-risk populations. So we can ask what psychosocial, cultural, and economic or other structural factors connect substitutes in HIV. As we saw from the CDC analysis earlier, there are a number of structural factors that seem to link the two epidemics. So syndemics is a concept from medical anthropology. It's an idea originally developed by Meryl Singer and it's a contraction of synergistic epidemics. The idea of synergism is not quite accurate. There aren't necessarily synergistic links between, for example, substance use and HIV. But the important idea about syndemics is that they are mutually enhancing, involving both interactions at the biological level as well as interactions at the community or population level due to social conditions, injurious social connections, or other structural factors. So the really important take-home about syndemics is that they involve structural, social, and biological factors interacting in the context of social marginalization. So the components of a syndemic are mutually reinforcing, meaning that treating one component often requires treating other components. And this idea of mutually enhancing or reinforcing components is to be distinguished from the idea of comorbid conditions or co-occurring conditions which don't reinforce or mutually enhance each other. As you can see from the earlier description of epidemiology, substance use and HIV, both of which are stigmatized conditions, affect populations that are marginalized and involve behaviors that are also stigmatized. So having HIV continues to be a highly stigmatized condition. Using substances, particularly injection substance use, both stigmatized and criminalized. Having mental illness, which co-occurs very frequently in folks with HIV or at risk for HIV, is a stigmatized condition, as well as minority sexual orientation, gender identity. And these conditions co-occur in populations who are already marginalized by race or ethnicity, housing status, income level, and other factors. So to illustrate the idea a little bit further regarding syndemics, in a sample of about 3,000 MSM, there was a high prevalence of polysubstance use, depression, childhood sexual abuse, intimate partner violence. These factors were associated with one another, independently associated with HIV seropositivity, and had an additive effect on HIV risk. So with an increasing number of risk factors, there was an increased risk of high-risk sex and HIV infection. A syndemic of HIV gender-based violence and substance use has been described among women and girls worldwide. So this nexus of HIV substance use and gender-based violence, which includes childhood sexual assault, intimate partner violence, forced sex work, and police violence, involves a vicious self-perpetuating cycle where, for example, intimate partner violence increases the risk of depression and the risk of HIV. Depression increases the risk of substance use. Substance use with partners increases the risk of intimate partner violence. And indeed, rates of intimate partner violence among women with HIV are quite high. In a number of studies, the rate is about 55%, which is double the national reported rate. And the rates of childhood sexual abuse and physical abuse were also more than double the national rate. Also among folks with HIV, or sorry, seeking addiction treatment generally, almost 90% in one study reported a history of trauma. Among women with HIV, there was 30% reported a history of trauma, as opposed to the population prevalence of 5%. So moving on to talk about screening and prevention, a recommendation from the CDC is universal HIV screening. That is opt-out screening in all health care settings. So the idea is that HIV screening should be done unless somebody chooses not to participate. And this is opposed to risk-based screening, which is only offered if a patient is identified as belonging to a high-risk group. And some of the benefits of that are that it removes the stigma associated with HIV testing. It's something that everybody gets, not just stigmatized populations. And it may detect HIV in patients who either because of their own self stigma or for other reasons are not known to be at risk for HIV. Another screening recommendation is on-site HIV testing and substance use treatment programs compared to testing off-site, testing that was done on-site in a substance treatment program increased the likelihood of testing and of, well, just of testing. With regard to substance use disorder screening and treatment, the U.S. Preventive Services Task Force recommends screening by asking about unhealthy drug use in all adults 18 years and older. So not just folks who are thought to be at higher risk for substance use, but asking all adults 18 years of age or older. There's also a recommendation that came out of a National Academies workshop in response to the opioid epidemic recommending or an action item suggesting immediate treatment of opioid use disorder in any healthcare setting and integrated screening and treatment of opioid use disorders in healthcare settings rather than referral to separate substance use settings. Just a very brief bit about taking a substance use history. It helps to build the alliance with a patient and also helps you to understand them if you ask about the function of their use. So at later stages of addiction, often people use just because their addiction has progressed and it's become compulsive. But at earlier stages, it often serves a reinforcing, it has a reinforcing benefit. So it may either be positively reinforcing increasing pleasure or negatively reinforcing decreasing pain or negative affect. So this is a quote from one of my patients. When I drink, I can escape from my regrets about life. So in this person's case, drinking is serving, is negatively reinforced because it relieves pain. Also ask about the function of substance use, being mindful of the psychosocial factors in which somebody is, that affect somebody's life. So this other patient said that, and this is very frequent among folks who are experiencing homelessness, they tell me that they have to stay awake at night to avoid assault. So they use stimulants in order to stay awake. So here's another example of a structural factor that is driving substance use and driving risk for HIV. Highly effective prevention intervention are syringe services programs. As I mentioned earlier, there's been a dramatic decline in the number of HIV infections attributable to injection drug use. And this is largely due to syringe services programs. So what they do as a basic service is allow folks who inject drugs to exchange used injection equipment, non-sterile equipment for new sterile equipment, thereby reducing the chances of sharing, removing contaminated equipment from the community, and reducing the risk of HIV and hepatitis C transmission. And although there have been some doubts about the effectiveness of SSPs or voiced, it's been at this point, well-documented that they are strongly associated with reductions in HIV transmission. Other services that they provide are, which are very helpful, are HIV counseling and testing, distribution of Narcan, the overdose reversal agent, referral to substance use treatment, including medication-assisted treatment. In one study, folks who participated in syringe exchange programs were five times more likely to enter substance use disorder treatment than those who did not. There has been limited adoption of syringe services programs in vulnerable communities, in part because of the belief that they would increase substance use in the area where they were established or facilitate local crime. But a systematic review in 2007 found no evidence that that was the case. In fact, as I just mentioned, the participation in a syringe services program seems to facilitate participation in substance use disorder treatment. Another study found that those who did participate simultaneously in a syringe service program and substance use disorder treatment reported fewer days of opioid and cocaine use, less injection drug use, fewer illegal activities, and less incarceration. Despite this, despite the effectiveness of SSPs in reducing the spread of HIV through injection drug use, vulnerable counties, the ones identified in the analysis after the outbreak in Scott County, have been very, very slow to implement SSPs. Less than a quarter of the identified vulnerable counties were operating syringe exchange programs in 2018. You can see the red dots are vulnerable counties that have not implemented syringe exchange. The blue dots and the blue areas are places that have. So barriers to implementation, as I mentioned, are fear of increased drug use, fear of increased crime. There's moral objections. Also criminalization of drug paraphernalia possession is a barrier. For example, in Virginia, there was a law that passed in 2017 granting certain counties the ability to operate syringe exchange programs, but it required public health officials to obtain formal consent from local law enforcement because the legislation did not exempt participants from the drug paraphernalia laws in effect. Other barriers to effectiveness are restricting the exchange to a one-to-one exchange, meaning somebody has to give one used syringe for every syringe returned that's not used, and this limits the ability of folks who then go on to inject drugs to have a sufficient supply of sterile syringes. There's practices where identifying data can be collected and sometimes is required to be collected, which obviously makes people reluctant to use the services, and there are often funding and resource shortages. The pandemic has had an effect on SSPs. Forty-three percent have reported a decreased availability of services. One quarter reported that one or more of their sites had closed, and they are offering their supplies in different ways. Same way everything else is being offered differently now, they're using delivery or mail services. So one recommendation would be to, and one resource is the North American Syringe Exchange Network, and I would recommend that you look at their site and identify a syringe exchange near your place of practice. And they also have a resource kit for starting or supplying a syringe exchange. Another prevention tool that's very effective is pre-exposure prophylaxis, which is use of antiretroviral medication to prevent HIV infection among those at risk. So in terms of sexual behaviors, it reduces the risk of getting HIV from sex by about 99 percent. That's huge. Among IVDU folks who use drugs intravenously, there was one study that showed that when taken as prescribed, it reduces the risk of HIV acquisition by 74 percent. There's three types. Two are oral medications, Truvada and Dyscovi, which are essentially the same medication, very similar. Dyscovi has the exclusion of not being approved for folks who are at risk through vaginal sex. And then just recently, a long-acting integrase inhibitor injection was approved, which only has to be gotten every two months, I believe, whereas the oral medications have to be taken on a daily or close to daily basis. There are some dosing regimens that allow for dosing right before and after sexual activity among folks who don't have a lot of sexual activity. So as mentioned, when taken as prescribed, it greatly reduces HIV incidence. In offering PrEP, it's recommended that one first take a sexual history. I'm sorry, the opposite is recommended. It's recommended that one discuss PrEP as a neutral way of starting to take a sexual history. So that way, one avoids the discomfort that both patients and providers feel about talking about sexual behaviors. If patients in talking about their sexual history don't reveal any clear risk factors for HIV acquisition through sexual behavior or drug use, but nevertheless ask for PrEP, the recommendation is to go ahead and prescribe it anyway. Another resource is the CDC website that allows you to locate HIV testing, PrEP, pre-exposure prophylaxis, post-exposure prophylactics, and condom nearby. So moving on to treatment, medication-assisted treatment has been shown to be effective in retaining people on antiretroviral therapy, and because they are retained on antiretroviral therapy, they have better viral suppression. I'm going to speed up a bit because I'm mindful of the time. In an overall systematic review and meta-analysis of the various types of medication-assisted therapy, including methadone, buprenorphine, and long-acting injectable naltrexone, their use was associated with a 69% increase in uptake of antiretroviral therapy and a 45% increase in viral suppression. These slides, which I'm not going to review, describe some issues, in particular drug-drug interactions between medications used for opioid use disorder treatment or alcohol use disorder treatment, or alcohol use disorder treatment, and HIV meds. There are also medications for alcohol use disorder treatment, which should be offered to folks who are diagnosed with alcohol use disorder, naltrexone in particular, and in particular the extended release formulation. Tisulfiram generally should not be co-administered with many medications that are used for HIV treatment. For meth use disorder, there was an excellent recent presentation by Dr. Schott on the approach to meth use disorder and treatment of meth use disorder with medication use. There's good evidence for the use of the combination of high-dose extended release Welbutrin along with injectable naltrexone, as well as mirtazapine. Behavioral treatments for stimulant use disorders, the most effective appears to be contingency management. There's also cognitive behavioral therapy that has a modest effect, and then peer support in the form of 12-step programs or other programs like Refuge Recovery, which is a Buddhist-inspired program, can be very helpful to a lot of people, and indeed are as effective. The use of peer support and facilitated 12-step treatment is as or more effective than CBT. There are some behavioral treatments that target multiple aspects of the syndemic condition, especially co-occurring psychiatric illness. One is seeking safety, which targets folks with a history of trauma and current trauma-related symptoms and HIV. Another one is Artemis, which is a positive affect intervention for MSM, so that is targeting both substance use and the depression that may lead to substance use or be a consequence of stopping substances, particularly methamphetamine. And then Project WINGS is a screening brief intervention and referral-to-treatment intervention for substance-using women experiencing intimate partner violence. So patients in the study sample, 70% of them had experienced intimate partner violence in the last 30 days. Those who received the intervention reported more engagement with intimate partner violence services and an increase in the number of days without substance use. As I just mentioned, 12-step involvement with facilitation is an effective evidence-based treatment for substance use disorders that is as or more effective than cognitive behavioral therapy. And this references a March 2020 Cochrane Review, which was a meta-analysis of 27 studies involving 10,500 participants comparing 12-step facilitation or 12-step involvement with other clinical interventions, including motivational enhancement therapy and CBT. There are also examples of culturally-informed care in community settings, so interventions that target subgroups at risk for HIV. An example near where I work is the Stonewall Project run by the San Francisco AIDS Foundation, which provides harm-reduction services for substance-using MSM. And then there are Puerto Rican groups, which are focused on populations that are principally Spanish-speaking, derived from AA. They are a form of 12-step support adapted for Spanish-speaking populations. There are nevertheless some issues in these culturally-informed possibilities for peer support. For example, many patients who are monolingual Spanish-speaking MSM or transgender report that they are harassed at, have been harassed at Spanish-language AA meetings because of their sexual orientation or gender identity. So that is it. These are references, and I think we can move on to Q&A. Okay. Thank you, Dr. Polignano, for a very interesting and informative presentation, and we appreciate you leaving so much time for questions. So I'm going to try and ask some of the questions that came into the question box. So you mentioned some of the medications that show some evidence for treating methamphetamine use disorder. The question is, and I don't know if you know the answer to this, are there studies going on for finding new medications? I don't know of specific studies. I'm sure that there are. But I would point out, as was pointed out in the recent webinar here, that the number needed to treat for both of the medications that I described, the buprenorphine plus, I'm sorry, bupropion plus extended-release naltrexone, as well as mirtazapine, the number needed to treat is about the same as for naltrexone in alcohol use disorder. So they aren't, well, I'll just leave it at that. They seem to be similarly effective. Okay. The next question is a little off-topic, but you might know the answer. It's certainly related. This person wants to know if there are people with HIV who got treatment for HIV, do they also typically receive treatment for hepatitis C? I can't speak to whether they typically receive treatment. They should receive treatment for hepatitis C. There are very, very effective treatments for hepatitis C that involve many fewer side effects than past treatments did. So they should be. So it's recommended that when folks are screened for HIV, they also be screened for various other, for hepatitis of various forms, hepatitis B, hepatitis C. Okay. So the next question, in the interest of time, you skimmed quickly over the drug-drug interactions that might occur between medications for substance use disorders and antiretroviral treatment. The question is, how do you handle the drug interactions between buprenorphine and antiretroviral therapy? I mean, to the best of my knowledge, there are not any clinically meaningful ones, but I may not be well-informed, so I'll toss the question to you. And so that's the answer. There aren't any clinically meaningful interactions. Okay. Great. That's good to know. Let's see. So someone had a question about the, let's see if I can find that question, about the syringe services of programs not requiring that any syringes be turned in in order to get new syringes. And I'm wondering if you could comment on the wisdom of that, and there was concern about used syringes being left in the community if they're not turned in. Sure. And that's an understandable concern. My understanding is that they do require syringes to be turned in, but not on a one-to-one basis. So they are willing to give out more syringes than are turned in. The hope is that those that are given out are then subsequently returned. But the idea is that if, say, somebody is initiating contact with the syringe services program, they may not have an adequate supply of sterile syringes. So if they bring, say, one or two used syringes and get back a much larger supply, then they're able to inject without having to reuse any of those syringes and presumably bring them back the next time they have contact with the syringe services program, or else safely dispose of them. Part of the reasoning behind that is that in studies of folks who are injecting drugs, they inject multiple times per day or multiple times per using session, and so they need more than one syringe that is sterile in order to reduce the chance of sharing. Thank you. There's another question about syringe services programs, and the question is, how can we rule out these programs introducing new patients to opioid usage? Well, presumably somebody is coming to the program already using substances, injecting substances of some form or another. So the risk of them being introduced to injection substance use by coming to a syringe service program seems low, and that's speculating on my part, but the data all say that syringe services programs do not increase rates of substance use generally and injection drug use in particular in communities where the programs are established. Great. The next question, I think, is a really important one, a hard one to answer in a few words, but I do want to put it out there and something we can all think about. The question is, how can providers ensure that they can offer a judgment-free supportive environment when asking questions about drug use and sexual behavior? So I'd love to hear your take on that, and it's just an idea that everyone should think about in person. What a great question, and I had wanted to talk more about stigma and the effects of stigma on access to care, as well as the effects of stigma on perpetuating an individual's substance use. There's a really great article by Nora Volkow, I don't know where or when it was published, she talks about the experience of having a stigmatized interaction with a health care provider by folks who are using substances, and she talks about the importance of social support in recovery from substance use and references what are known as the Rat Park experiments where rats who were given the choice between hanging out with other rats or using substances chose to hang out with other rats over substance use, over the use of very addictive substances like cocaine, whereas rats who were socially isolated and didn't have the option used more substances. So the suggestion is that by not offering care that is allowing and accepting that there is a risk that folks will then continue to use substances because of the experience of social isolation that results. So that's not really a direct answer to the question, the direct answer to the question would be to just listen to people and to find out how substances work in their lives. So rather than collecting information about symptoms, like how much and how often and what are the consequences, find out how they came to start using substances, what function do the substances serve for them. And similarly, sexual behaviors, if they're having high-risk sexual behaviors, how does that function for them? What does it allow them to do that they might not otherwise do? Or what does it help them to avoid feeling that they might otherwise have to feel? So there's some correlation, for example, between internalized stigma regarding in MSM and the use of substances to engage in high-risk sexual activity. So folks with higher levels of self-stigma may find themselves using substances to allow them to have sexual contact and intimacy, which they might otherwise not be able to do, given their level of internalized homophobia. So asking about, yeah. Even though we had a very vibrant Q&A session, we didn't get to all the questions. I apologize about that, but we do need to wrap up now. Thank you again, Dr. Polignano. If for those questions that didn't get answered, we will try and get you some written answers if possible. Next slide. Thank you for participating in today's session. Visit www.pcssnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder. PCSS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS Discussion Forum, a simple and direct way to receive an answer related to medication for substance use treatment. Next. Attendees who complete an evaluation of today's session can obtain a free CME or a Certificate of Participation. Attendees will receive instructions via email within one hour after this webinar concludes. The email will have a link to the evaluation survey and an access code. To claim credit, complete the survey linked in the follow-up email. You will then be directed to the credit claim page, which will ask for the access code. If you have any issues claiming credit, please reach out to educme at psych.org. Additionally, today's session was recorded. The presentation slides and video recording will be posted on the Provider's Clinical Support System website in two weeks following today's event. Next. Today's activity was presented on behalf of SAMHSA's funded Provider's Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. Next. Please join us for our next webinar on March 8, 2022, from 12 p.m. to 1 p.m. Eastern Standard Time as Dr. Kathleen Brady presents Women, Gender, and Substance Use Disorder. Again, this free webinar will be on Tuesday, March 8, from noon to 1 p.m. Eastern Standard Time. Next. Thank you for joining today. It's been a great webinar. We were lucky to have this time with Dr. Polignano. We hope to see you again soon. Thank you.

HIV

Substance Use Disorder

Intertwined Epidemics

Dr. Michael Polignano

SAMHSA-funded Providers Clinical Support System

Structural factors

Universal HIV screening

Syringe services programs

Pre-exposure prophylaxis

Medication-assisted treatment