In sub-Saharan Africa and globally, many persons who inject drugs (PWID) are living with undiagnosed or untreated HIV, experience high levels of poverty, food and housing instability, and discrimination, and have increased risk for health conditions that contribute to worse outcomes from COVID-19. It is also more challenging for PWID to access healthcare when services have been limited by lockdowns and measures to ensure social distancing to prevent spread of respiratory viruses, such as SARS-CoV-2. We propose to recruit and follow a cohort of 500 HIV-positive and 500 HIV-negative PWID and their partners, many of whom also have hepatitis C, to determine whether poorly controlled HIV infection, active drug use and other HIV- and PWID-specific risk factors result in increased likelihood of COVID-19 acquisition, viral transmission, symptomatic disease and poor clinical outcomes (AIM 1). We will also define transmission dynamics through phylogenetic analyses of SAR-CoV-2 sequences from symptomatic PWID (AIM 2) and determine whether HIV care and harm reduction service delivery disruptions are associated with poor compliance to ART and methadone, HIV viremia and other adverse outcomes (AIM 3). Our proposal is innovative in how it reaches PWID and partners using peer educators, employs targeted testing and symptom screening in this high-risk Kenyan population, and defines COVID-19 transmission within and beyond local networks using phylogenetics. Participant recruitment and enrollment will take place in drop-in centers and methadone clinics in Nairobi, Mombasa and Kilifi, Kenya and follow-up visits will occur monthly for 6 months. In addition to collecting interview data and blood for SARS- CoV-2 antibodies, we will ask participants who have symptoms consistent with COVID-19 at any of the 7 visits to self-collect a nasal swab specimen for SARS-CoV-2 polymerase chain reaction (PCR), followed by genome sequencing if positive. Laboratory assays for antibody and viral PCR testing will be conducted in Nairobi and positive specimens will be shipped to Seattle for sequencing and phylogenetic analysis. We anticipate that our results will highlight the need for targeted testing among PWID and inform interventions and programs for HIV and addiction care and treatment across the globe for similar marginalized populations when confronted with COVID-19 and other public health crises.
People who inject drugs (PWID), especially those who are HIV-positive or actively injecting, are likely to experience high SARS-CoV-2 infection, transmission, morbidity and mortality from COVID-19, especially in sub- Saharan Africa, where high HIV prevalence, extreme poverty and high population density exacerbate the situation. In this supplement to our parent award we will determine the extent to which HIV, hepatitis C and active drug use increase risk of COVID-19, examine transmission among PWID and partners, and characterize how disruption of HIV and harm reduction services influences outcomes. This will lead to improved testing, clinical care and public health strategies that will address the needs of this population and control spread across populations during the COVID-19 pandemic.