The COVID-19 pandemic, caused by the SARS-CoV-2 virus, took the world by surprise in early 2020 and resulted in unprecedented disruptions to normal life throughout the world as measures were put in place to control the spread of the deadly virus . Across North America, COVID-19 swept across the United States and Canada overwhelming health services and health infrastructure as cases exploded, hospitalizations exceeded capacity, and businesses and public programs like schools were forced to shut their doors, go online, or on hiatus . The physical and social impact was enormous – death rates grew exponentially and the healthcare system was pushed to exceed capacity in the face of enormous caseloads and a virus that spread rapidly . As schools, clinics, social venues, and otherwise non-essential businesses shut their doors, the most vulnerable in our society including those marginally housed, those experiencing substance use and/or those with mental health issues were even further marginalized as a result of lost services and support . Early in the pandemic, signs of increases in substance use raised concerns that substance use would skyrocket . Overdoses and particularly overdose deaths hit unprecedented levels and partially because of the reduced availability of emergency medical services . People living with HIV and particularly those who are not virally suppressed, were considered to be at heightened risk for COVID-19 serious consequences because of being immunocompromised and experiencing high prevalence of comorbidities . Among such individuals are people who use drugs and those with mental health problems . Therefore, understanding patterns of who did not obtain COVID-19 testing among PWUD and PLWH provides insight into how those with intersectional challenges may have experienced systematic exclusion from public health initiatives during the COVID-19 pandemic. This may shed light on strategies that may help us enhance access to testing among marginalized populations who experience health inequities in a future public health crisis.

To assess the impact of the COVID-19 pandemic among those confronting multiple challenges such as substance use and HIV,cannabis drying trays a consortium of NIDA funded cohorts entitled the Collaborating Consortium of Cohorts Producing NIDA Opportunities launched a specially designed survey administered three times during the pandemic. The C3PNO COVID-19 survey module contained specific measures for PWUD and PLWH. These data provide insight into the compelling questions of change in the levels of substance use among those enrolled in the cohorts many of whom have been using long term, been in substance use treatment, and have heavy use . Moreover, the results may demonstrate the extent to which critical COVID-19 public health interventions such as testing for the virus reached PWUD and PLWH. The C3PNO consortium was uniquely positioned to identify impacts of the COVID-19 pandemic on PWUD and PLWH as its cohorts following large numbers of such individuals across North America. The analyses described herein focus on the prevalence and factors associated with COVID-19 testing among PWUD and PLWH who participated in the first two rounds of the C3PNO COVID-19 module. C3PNO was established in 2017 by the National Institute on Drug Abuse to enhance data sharing opportunities and mechanisms to facilitate collaborative research efforts among NIDA-supported cohorts that examine HIV/AIDS in the context of substance misuse. Details of the participating cohorts and other methodology have been previously described but in sum, the C3PNO consortium is comprised of nine NIDA cohorts located in major cities throughout North America with a combined sample size of up to 12,000 active participants. Some cohorts had initial enrollment criteria that participants be people who inject drugs while other cohorts are young men who have sex with men. The consortium links a wide range of behavioral, clinical, and biological data from diverse individuals at high-risk for HIV or living with HIV participating in the cohorts. Starting in May 2020, the consortium launched a survey to examine patterns of substance use, substance use disorder treatment, and utilization of HIV prevention and care services in the midst of the COVID-19 pandemic.

Specific domains collected as part of the survey included overall impact of the COVID-19 pandemic and related governmental/societal restrictions on day-to-day life, adoption of COVID-19 prevention practices, COVID-19 testing and symptomatology, changes in substance use behaviors as well as reports of pandemic impact on access, quality, and pricing of illicit substances. The survey also included various measures of mental health including anxiety as well as access to medical care and substance use treatment. At the time of this study COVID-19 testing was available and recommended mostly for those with symptoms defined by the CDC at the time as the most predictive of COVID-19 infection including: fever, feeling feverish, chills, repeated shaking with chills, muscle aches or pain, runny nose, sore throat, new or worsening cough, shortness of breath, nausea or vomiting, headache, abdominal pain, diarrhea, and sudden loss of taste or smell. In the survey module current symptom reports were collected. Eight of the nine C3PNO cohorts participated in both of the first rounds of data collection but one was unable to share its data – all nine cohorts joined for later rounds. Each participating cohort contacted a minimum of 200 of their cohort members to participate in the survey eligible if they: were previously enrolled in one of the eight participating C3PNO cohorts; participated in a recent study visit ; were English and/or Spanish speaking; and willing and able to complete the survey remotely. Cohort investigators were encouraged to enroll participants who had a recent history of substance use as determined by self-report at their most previous visit. The survey was either self-administered through a web based survey for participants that had computer and internet access or interviewer administered by telephone for those participants without online access. The survey took approximately 20 min to complete and participants were remunerated for their time. The study was approved by the institutional review boards of the consortium cohorts and each participant provided informed consent for their study participation. There were 4035 responses to the survey across all eight cohorts that participated in both of the first two rounds and collected fully analyzable data; 3762 were available for this analysis because the Canadian cohorts confronted restrictions with sending data and were not able to be included.

The analyzed data for this manuscript includes data from 2331 individuals who completed one or both of the first two rounds of the C3PNO COVID-19 module. Participants were offered participation in each round of the survey regardless of participation in first round. This resulted in 1431 from individuals responding to both rounds. The first round was conducted from May-November 2020 and the second round from October 2020 through April 2021. Median time between surveys for participants who completed both rounds of the survey was 4.1 months . The time to implement the survey was a window period starting from when the programmed survey was made available for each round . Intervals are overlapping because some cohorts had not finished their first round when the first cohorts to implement started their second round. The survey was implemented in a very challenging time of research administration with entire components of universities shut down for months delaying aspects of survey conduct such as reviews of research and procedures for compensation. Therefore, the cohort research teams did the best they could to administer the survey when available and to reach the requested minimum number of participants and there was a range in time as to how long it took them to be able to collect data. Moreover,heavy duty propagation trays the implementation of the survey resulted in different time frames required by cohort research teams to complete the data collection. Those that sent links to web-based questionnaires and had participants who were responsive to these completed the rounds relatively quickly . Other cohorts had many older participants who had to be interviewed by telephone . These teams required much more time to reach participants and conduct the interviews. We implemented and conducted this research in a unique and challenging time in history that required some flexibility and innovations in data collection. This means because of the geographic range captured in these surveys, participants in different cities responded during different phases of the pandemic. Finally, given the burdens on the cohort staff to implement this study in addition to their other work, systematic data on refusal rates were not able to be collected. Specifically, participants were asked if they were tested for COVID-19 and if yes, if they have ever tested positive. Participants were also asked if they had symptoms of COVID-19. Participants were considered to have recent substance use if they reported using any of the following substances in the past month: methamphetamine, cocaine, heroin, fentanyl, or misused prescription opioids.

Alcohol, tobacco, and cannabis use were also assessed but are not the focus of these analyses. Univariate analyses provided descriptive statistics for the sample overall and by COVID-19 testing status. Comparisons of demographics, substance use and frequency of use, as well as HIV-status by COVID-19 testing status were based on t-tests, chi-square methods, and other non-parametric tests as appropriate while adjusting for the effect of the subject . Factors associated with the outcome of interest were assessed using regression analysis with generalized estimating equations in order to account for the within-subject correlations. This large survey of COVID-19 testing experience among cohorts that follow people living with HIV and people who use drugs across North America provides a snapshot of how the COVID-19 pandemic in its first year may have impacted those who live on the margins of society. This sample included those among the most socially vulnerable in North America – over half were unemployed before the pandemic, about one third food insecure, many people of color almost half of whom were living with HIV. Many of these individuals are not in the formal economy that may partially explain why only half of them were tested for COVID-19 – the entry point into COVID-19 prevention . It is also of concern that across surveys those reporting having COVID-19 symptoms did not have higher testing rates than those who didn’t report symptoms, although the recommendation and priority for COVID-19 was testing of those symptomatic early in the pandemic when testing was limited by supply of tests. Testing continues to be a pillar of COVID-19 control; especially before vaccine availability when these surveys were implemented . Our findings show that lack of COVID-19 testing was associated with markers of social marginalization such as unemployment. As many workplaces began offering testing to their employees, this can explain why unemployed had less opportunity for testing. Fewer Black participants reported testing, and this parallels what has been seen in studies of the more general population . This may be related to historical mistrust with the healthcare system and negative experiences of Black individuals with public health interventions that have previously exploited or misled them . Another key finding was that fewer PLWH reported COVID-19 testing than people HIV negative in these cohorts. That may be because our PLWH were older, more were Black, and more reported frequent substance use representing intersectional marginalization that may have kept them from accessing a COVID-19 test . The finding that fewer PLWH accessed COVID-19 testing suggests that COVID-19 services may have been less available in places they mostly access care such as their HIV treatment clinics because early in the pandemic there was less in-person HIV care. Moreover, it is possible that because PLWH have weakened immune systems they may been aware of their heightened vulnerability so vigilantly practiced masking and social distancing. While the substance use reported in the month before the survey does not seem high among cohorts of people who use drugs, it must be clarified that our study defined substance use by use of highly addictive, i.e. “hard” or street drugs such as methamphetamine, heroin, cocaine, fentanyl and prescription opioids. Use only of alcohol, tobacco and cannabis were not included in this analysis as the focus was on how the pandemic affected those who use highly addictive illicit substances that usually becomes a dominant part of their lives.