https://orcid.org/0000-0001-9385-9049
Figures
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately impacted people who use drugs (PWUD). This study explored relationships between drug use, COVID-19 testing, vaccination, and infection. This cross-sectional study was conducted in Miami, Florida between March 2021 and October 2022 as part of the National Institutes of Health (NIH) Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative and the Miami Adult Studies on HIV (MASH) cohort. Users of cannabis, cocaine/crack, heroin/fentanyl, methamphetamines, hallucinogens, and/or prescription drug misuse in the previous 12 months were considered PWUD. Sociodemographic data, COVID-19 testing history, and vaccination-related beliefs were self-reported. Vaccinations were confirmed with medical records and positivity was determined with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. Statistical analyses included chi-square tests and logistic regression. Of 1,780 participants, median age was 57 years, 50.7% were male, 50.2% Non-Hispanic Black, and 66.0% reported an annual income less than $15,000. Nearly 28.0% used drugs. PWUD were less likely than non-users to self-report ever testing positive for SARS-CoV-2 (14.7% vs. 21.0%, p = 0.006). However, 2.6% of participants tested positive for SARS-CoV-2, with no significant differences between PWUD and non-users (3.7% vs. 2.2%, p = 0.076). PWUD were more likely than non-users to experience difficulties accessing testing (10.2% vs. 7.1%, p = 0.033), vaccine hesitancy (58.9% vs. 43.4%, p = 0.002) and had lower odds of receiving any dose of a COVID-19 vaccine compared to non-users (aOR, 0.63; 95% CI, 0.49–0.81; p<0.001). PWUD presented with greater difficulties accessing COVID-19 testing, greater vaccine hesitancy, and lower odds of vaccination. Testing and immunization plans that are tailored to the needs of PWUD and consider access, trust-building campaigns, and education may be needed.
Citation: Tamargo JA, Martin HR, Diaz-Martinez J, Delgado-Enciso I, Johnson A, Bastida Rodriguez JA, et al. (2024) Drug use and COVID-19 testing, vaccination, and infection among underserved, minority communities in Miami, Florida. PLoS ONE 19(4): e0297327. https://doi.org/10.1371/journal.pone.0297327
Editor: Harapan Harapan, Universitas Syiah Kuala, INDONESIA
Received: June 28, 2023; Accepted: December 24, 2023; Published: April 30, 2024
Copyright: © 2024 Tamargo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was supported by the National Institute on Drug Abuse [U01DA040381 and 3U01DA040381-05S2] [MKB] [https://nida.nih.gov/] and the National Institute on Minority Health and Health Disparities [U01MD017423] [MKB] [https://www.nimhd.nih.gov/]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately impacted people who use drugs (PWUD), who are among the most socially vulnerable populations [1–3]. Social vulnerability refers to the negative effects of external stressors on the health of communities; stressors such as lack of income, limited transportation and healthcare access, as well as housing insecurity may weaken a community’s ability to prepare for and respond to hazardous events [4]. Indeed, PWUD are more likely to live in poverty [5], experience housing instability, and have difficulty accessing healthcare [6]. Over 20% of the United States (U.S.) population use illicit substances [7], and the COVID-19 pandemic has led to exacerbation of substance use [8, 9].
Despite the effectiveness of COVID-19 vaccination in preventing severe illness, hospitalization, and death due to COVID-19 [10], vaccination rates remain low among U.S. minorities [11]. Barriers to vaccination may include poor access to vaccination sites, fear of mistreatment by medical professionals, and mistrust of the medical community [12, 13]. Sources have reported hesitancy rates of approximately 19.8% in the U.S. [14], while literature on global COVID-19 vaccine acceptance and hesitancy have reported hesitancy rates as high as 33.0% in the U.S. [15]. PWUD may also encounter barriers that limit vaccination access such as lack of transportation [16], limited healthcare access [6], concerns about stigma and discrimination [17], and complexity of booking systems [18, 19]. In a survey of PWUD, nearly half expressed unwillingness to take a COVID-19 vaccine, citing concerns of adverse effects and skepticism of risk of infection [20]. Studies investigating people who inject drugs have indeed reported lower COVID-19 vaccination rates in Australia and Baltimore, Maryland in the U.S. [18, 21]. Reports of lower flu vaccine [22, 23] and hepatitis A and B vaccine uptake [24, 25], as well as low willingness for a potential HIV vaccine uptake among PWUD have also been published [26]. Nevertheless, data regarding COVID-19 vaccine uptake among PWUD in the Southern U.S. is lacking.
Studies have reported PWUD are at an increased risk of severe COVID-19 illness, hospitalization, and mortality [27–29], potentially due to the same structural and social factors that contribute to the community’s social vulnerability. PWUD may also be at risk of poor COVID-19 outcomes due to underlying cardiometabolic comorbidities and pulmonary damage caused by use of illicit substances [28–31]. Many drugs of abuse also have immunosuppressive properties that may promote infection and disease progression [32, 33]. Opioids have been shown to exert suppressive effects on both the innate and adaptive immune systems [34], while methamphetamines have been reported to cause immune dysregulation in the lungs [35]. Smoking of cannabis can damage lung tissue leading to inflammation and diminished capacity to respond to respiratory infections [30], while cocaine, methamphetamines, and opioids have all been reported to negatively affect the cardiovascular system [28]. Altogether, many drugs of abuse, including cannabis which has been reported to be more socially acceptable in the U.S. [36], may have adverse physiological effects that may increase the risk for poor COVID-19 outcomes. Taken together with the social vulnerability that accompanies drug use [1], strategies are needed to monitor and prevent the spread of COVID-19 among PWUD.
COVID-19 testing, another critical component in controlling the spread of COVID-19, has also not been well investigated among PWUD. In this study, we explored relationships between drug use, COVID-19 testing, vaccination, and infection.
Materials and methods
Study design
This cross-sectional study was conducted as part of the National Institutes of Health (NIH) Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative; a consortium of more than 135 projects studying COVID-19 testing patterns in underserved communities across the U.S. The overall aim of RADx-UP is to investigate COVID-19 testing patterns in historically marginalized and underserved communities across the U.S. with the aim of speeding innovation in the development and implementation of testing. More information can be found at https://radx-up.org/about/. The data presented herein were collected from an individual RADx-UP project site located in Miami, Florida as part of RADx-UP Phases I and II between March 30, 2021 and October 13, 2022. Phase I recruited participants and collected data from March 2021 to February 2022 and Phase II then recruited participants and collected data from May 2022 to October 2022. Both our Phase I and II projects collected the same variables, and each Phase recruited new participants. Importantly, Miami-Dade County experiences a high level of social vulnerability [37]; the COVID-19 Community Vulnerability Index scored Miami Dade as 0.90 which indicates “very high” COVID-19 vulnerability [38]. Recruitment for this RADx-UP project site included community members from socioeconomically disadvantaged Black and Hispanic neighborhoods and participants of the Miami Adult Studies on HIV (MASH) cohort; a prospective cohort study funded by the National Institutes on Drug Abuse (NIDA) that follows more than 1,000 underserved minority Black and Hispanic adults living with and without HIV and high rates of substance use [39]. The protocol for this study was approved by the Institutional Review Board (IRB) at Florida International University (FIU). The authors had access to information that could identify individual participants during and after data collection; IRB-approved privacy and confidentiality protocols were adhered to. The data were accessed for this study between September 2021 and June 2023. All participants provided verbal informed consent to participate in the study over the phone which was witnessed and documented by two trained research assistants. Written consent was not obtained due to COVID-19 precautionary measures, which was approved by the FIU IRB.
Data collection
Due to COVID-19 precautionary measures, participants completed questionnaires by phone with a trained interviewer. Exceptions for in-person questionnaires were made for participants without access to a phone or with difficulty communicating over the phone. A screening consisted of sociodemographic and eligibility questions. Inclusion criteria consisted of being 18 years of age and older. Participants were excluded if they were pregnant, unwilling to complete the survey, and/or unwilling to undergo COVID-19 testing. If eligible, participants completed the survey which included RADx-UP common data elements (CDEs) and additional questions implemented by our project site which included measures of substance use behaviors, comorbidities, and health disparities. After participants completed the survey over the phone, they were provided an appointment for COVID-19 testing at our clinic, located in central Miami, Florida. Participants were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with real-time reverse transcription-polymerase chain reaction (rt-PCR) in our Clinical Laboratory Improvement Amendments (CLIA)-certified COVID-19 lab. Medical personnel performed sampling, with participant’s choice of nasopharyngeal swab or saliva. Participants were compensated $15 for completing the screening and $40 for completing the survey with COVID-19 testing.
The RADx-UP CDEs include items from the NIH CDE Repository, Disaster Research Response (DR2) guidelines, and the PhenX Toolkit. The RADx-UP consortium selected and further refined community-informed CDEs via an iterative process to support standardized data collection [40]. The RADx-UP CDEs and sources are available at https://radx-up.org/. Sociodemographic data, alcohol and tobacco use, COVID-19 testing history and related beliefs, and COVID-19 vaccination-related beliefs were self-reported. Employment status was assessed with a PhenX protocol item, “We would like to know about what you do—are you working now, looking for work, retired, keeping house, a student, or something else?”. A response of, “Disabled, permanently or temporarily” was used to denote disabled employment status which differed from an unemployed status which was defined as a response of, “Only temporarily laid off, sick leave or maternity leave”, or “Looking for work, unemployed”. COVID-19 status at the time of the study was determined with rt-PCR testing for SARS-CoV-2 as described above. COVID-19 vaccinations and HIV status were confirmed with medical record documentation. We confirmed 81.8% of all self-reported COVID-19 vaccines by compensating participants an additional $5 for a copy of their vaccination record card. HIV viral load and CD4 cell counts were abstracted from medical records for participants living with HIV, following consent.
PWUD
We use the term “PWUD” to refer to people who use illicit substances including cannabis and misuse of prescription drugs. Participants were asked about their use of marijuana in the past 12 months (yes, no). Our rationale for including cannabis was that it remains illicit at the federal level, can be abused, and there exists ample evidence of the possibility of cannabis dependence [41]. Cannabis remains the most widely used illicit drug [7], and poor health outcomes have been observed even among people who use marijuana for at least some therapeutic purposes [42]. Misuse of prescription drugs was assessed by asking, “In the past 12 months, how often have you used prescription drugs just for the feeling, more than prescribed, or that were not prescribed for you?” (never, rarely, about once per month, about once or twice per week, daily or almost daily); misuse of prescription drugs was considered as, “about once per month” or more frequently. Lastly, participants were asked, “In the past 12 months, have you used any of the following drugs: cocaine or crack, heroin, fentanyl, crystal meth (methamphetamine), hallucinogens (like LSD, psilocybin, PCP, ketamine), ecstasy?” (yes, no).
Statistical analysis
Descriptive statistics are presented as counts (percent, %) for categorical variables and mean ± standard deviation (SD) or median (Q1 –Q3) for continuous variables depending on the normality of the distribution of the variable which was assessed with the Shapiro-Wilk test and examination of histograms. Between-group differences were tested with chi-square test and t-tests (Wilcoxon rank-sum test for variables with skewed distributions) for categorical and continuous outcomes, respectively. The main exposure of interest was drug use. The primary outcomes were COVID-19 testing, vaccination, and infection. Binary logistic regressions were performed and reported as prevalence odds ratios (OR) with 95% confidence intervals (CI). Multivariable regression models adjusted for age, sex, race/ethnicity, education level, and history of lung disease. COVID-19 vaccination status was also included as a covariate for the regression models with COVID-19 positivity as the outcome. The variance inflation factor method was used to ensure absence of collinearity between independent variables. Missing data were treated as missing at random and were excluded from respective analyses, as previously suggested [43]. Results were considered statistically significant at two-tailed p<0.05. All statistical analyses were conducted using SAS OnDemand for Academics (SAS, Inc. Cary, NC).
Results
Cohort characteristics
A total of 1,781 and 153 RADx-UP participants were screened for possible inclusion into Phases I and II, respectively. Participants were excluded from analysis due to ineligibility or unwillingness to complete the survey, not attending their testing appointment, and/or missing substance use data (Fig 1). A total of 1,681 participants from Phase I and 99 participants from Phase II were included (n = 1,780); 533 (29.9%) were MASH cohort participants. Nearly 28.0% reported using drugs, including cannabis (23.4%), cocaine/crack (5.5%), misuse of prescription drugs (0.9%), hallucinogens (0.6%), heroin and/or fentanyl (0.5%), and methamphetamines (0.4%) (Table 1, Fig 2). Due to the small proportions (<1%) of those who reported use of drugs other than cannabis or cocaine/crack, we were unable to appropriately conduct analyses stratified by each drug type separately. Thus, we report comparisons between those who reported use of any illicit drug vs. those who reported no drug use. Additionally, 35.8% smoked cigarettes, 4.5% consumed alcohol four or more days per week, and 10.3% engaged in binge drinking. Compared to those who did not use drugs, PWUD were more likely to smoke (27.2% vs.58.6%, p<0.001), engage in frequent alcohol use (2.0% vs.10.0%, p<0.001), and binge drink (7.3% vs. 15.5%, p<0.001) (Table 1).
A visualization of the flow of screening, exclusion, enrollment, testing, and final sample size of the analysis. Abbreviations: RADx-UP, Rapid Acceleration of Diagnostics–Underserved Populations.
A visualization of the percentage of participants who reported substance use stratified by type of substance. Cannabis use was defined as a response of “yes” to “Have you used marijuana in the past 12 months?”. Cocaine/crack use, hallucinogen use, heroin/fentanyl use, and methamphetamine use was defined as a response of “About once per month”, “About once or twice per week”, or “Daily or almost daily” to “In the past 12 months, have you used any of the following drugs: cocaine or crack, heroin, fentanyl, crystal meth (methamphetamine), hallucinogens (like LSD, psilocybin, PCP, ketamine), ecstasy?” for each of the individual drugs. Prescription drug misuse was defined as a response of “About once per month”, “About once or twice per week”, or “Daily or almost daily” to “In the past 12 months, how often have you used prescription drugs just for the feeling, more than prescribed, or that were not prescribed for you?”. Abbreviations: RADx-UP, Rapid Acceleration of Diagnostics–Underserved Populations.
The median age of participants was 57.0 (49.0–63.0), 50.7% were male, 50.2% identified as Non-Hispanic Black, 34.8% as Hispanic White, and 5.8% as Non-Hispanic White; 63.3% obtained a high school education or less, 37.0% were disabled, 22.6% were living with HIV, and 21.7% were employed (Table 1). Compared to those who did not use drugs, PWUD were more likely to be slightly younger, male, Non-Hispanic Black, and living with HIV, and less likely to have a college degree. PWUD were also more likely to live alone (42.9% vs. 38.9%, p = 0.010), report housing insecurity (21.9% vs. 11.2%, p<0.001), employment disability (41.3% vs. 35.3%, p<0.001), and loss of income since the start of the COVID-19 pandemic (39.0% vs. 28.9%, p<0.001), compared to non-users. Sixty-seven percent of the sample reported having public health insurance (Medicare and/or Medicaid), but PWUD were more likely than non-users to report no insurance or not knowing (25.3% vs. 16.3%, p<0.001). In addition, both PWUD and non-users had similar incomes, approximately two-thirds of both groups reported an annual income of less than $15,000, which reflects the social vulnerability of this sample (Table 1).
COVID-19 testing and positivity
Nearly 16.0% of participants had never been tested for COVID-19 prior to participation in the study. Of those who had been tested (84.2%), 19.3% reported ever testing positive. Of those ever testing positive, 68.9% reported having moderate-to-severe symptoms, and 19.7% reported being hospitalized due to COVID-19. While there was no difference in the proportions of those who self- reported ever being tested for COVID-19 (83.3% in PWUD vs. 84.6% in non-users, p = 0.499), PWUD were less likely than non-users to self-report ever testing positive (14.7% vs. 21.0%, p = 0.006). However, 2.6% of participants tested positive for SARS-CoV-2, which tended to be more frequent among PWUD than non-users (3.7% vs. 2.2%, p = 0.076) (Table 2). Of eligible participants, 108 (5.7%) failed to arrive for COVID-19 testing, however the proportions of PWUD and non-users who failed to complete COVID-19 testing were not significantly different (6.3% vs. 5.5%, p = 0.495).
Attitudes and beliefs about COVID-19 testing
There were no significant differences in the proportions of those who self- reported ever being tested for COVID-19 by drug use. However, when asked, “Have you ever tried to get tested for COVID-19 but were unsuccessful?” a greater proportion of PWUD reported, “yes” than non-users (10.2% vs. 7.1% respectively, p = 0.033), indicating a lack of testing access. The majority of participants reported being confident or very confident about COVID-19 testing results, but fewer trusted a positive (68.5%) than a negative (81.2%) result. On the other hand, PWUD were less likely than non-users to trust a negative result (77.8% vs. 82.6%, p = 0.020). When asked about perceived benefits of COVID-19 testing, over 80% of participants agreed with all prompts (Table 2). However, when asked about perceived risks of being tested, PWUD were more likely than non-users to report, “May experience discomfort from being tested” (20.3% vs. 15.5%, p = 0.016) and, “Difficult to get needed healthcare if I have it” (13.3% vs. 9.6%, p = 0.023). When asked about what a positive result meant, PWUD were more likely than non-users to report, “I will need to be admitted to the hospital” (51.2% vs. 40.5%, p<0.001) and, “I will need to take off work” (80.6% vs. 68.0%, p<0.001). When asked how serious they thought it would be if they got COVID-19, PWUD were more likely than non-users to report moderately-to-very serious (64.5% vs. 52.6%, p<0.001) (Table 2).
COVID-19 vaccinations
Nearly 76% of the sample (75.8%) had received at least one dose of a COVID-19 vaccine (Table 3). PWUD, compared to non-users, were less likely to have received a flu vaccine that season (40.1% vs. 47.5%, p = 0.019) and any dose of a COVID-19 vaccine (65.5% vs. 79.7%, p<0.001) (Table 3). Multiple binary logistic regression estimated that PWUD had 37% lower odds of being vaccinated against COVID-19 compared to non-users after adjustment for age, sex, race/ethnicity, education, and history of lung disease (aOR, 0.63; 95% CI, 0.49–0.81; p<0.001) (Table 4). When stratified by type of drug used, use of cannabis was associated with 32% lower odds of being vaccinated (aOR, 0.68; 95% CI, 0.52–0.88; p = 0.003), and illicit drug use excluding cannabis (cocaine or crack, heroin, fentanyl, methamphetamine, hallucinogens, or ecstasy) was associated with 47% lower odds of being vaccinated (aOR, 0.53; 95% CI, 0.37–0.75; p<0.001). Due to the small proportions (0.4%-0.9%) of those who reported use of drugs other than cannabis or cocaine/crack (Fig 2), we were unable to conduct analyses stratified by each drug type separately. Of those participants who had received at least one dose of a COVID-19 vaccine, PWUD were less likely to have completed the initial vaccination series (90.2% vs. 94.0%, p = 0.026), compared to non-users (Table 3). Additionally, PWUD were also more likely to have refused a vaccine in the past (COVID-19 vaccines among other vaccines) (20.2% vs. 12.8%, p<0.001), compared to non-users. Among those who were unvaccinated against COVID-19 (n = 426), 49.5% reported not being likely to vaccinate and a greater proportion of PWUD reported they were not likely to vaccinate compared to non-users (58.9% vs. 43.4%, p = 0.002) (Table 3).
Reasons for getting/not getting a COVID-19 vaccine
While 88.5% agreed with, “COVID-19 vaccination is an effective way to prevent and control COVID-19”, 30.1% agreed with, “The side effects of most vaccines outweigh the benefits” (Table 3). Notably, PWUD were less likely than non-users to agree with, “COVID-19 vaccination is an effective way to prevent and control COVID-19” (85.8% vs. 89.5%, p = 0.041). PWUD largely agreed with non-users on reasons for getting a COVID-19 vaccine, but PWUD were less likely to report, “I want to keep myself safe” (79.8% vs. 84.3%, p = 0.025). In terms of reasons for not getting a COVID-19 vaccine, PWUD, compared to non-users, were more likely to report, “I don’t like needles” (11.4% vs. 8.1%, p = 0.027), “I’m not concerned about getting really sick from COVID-19” (8.8% vs. 4.7%, p = 0.001), “I’m concerned about side effects from the vaccine” (41.4% vs. 35.4%, p = 0.018), “I don’t think vaccines work very well” (16.3% vs. 10.2%, p<0.001), “I don’t trust that the vaccine will be safe” (33.7% vs. 23.0%, p<0.001), “I don’t believe the COVID-19 pandemic is as bad as some people say it is” (6.9% vs. 3.3%, p = 0.001), “I don’t want to pay for it” (11.6% vs. 5.7%, p<0.001), and, “I don’t know enough about how well a COVID-19 vaccine works” (35.7% vs. 24.8%, p<0.001). Additionally, PWUD, compared to non-users, were less likely to agree with, “If I decide to get the COVID-19 vaccine, it would be hard to find a provider that could give me the vaccine” (7.8% vs. 12.9%, p = 0.003).
Discussion
People who use drugs are a socially vulnerable population [1–3] who experience high rates of poverty [5], housing instability, and difficulty accessing healthcare [6]. Taken together with the underlying cardiometabolic comorbidities and pulmonary damage caused by illicit substances [28–31] as well as the immunosuppressive properties that characterize a wide range of drugs [32, 33], PWUD have the potential to be greatly impacted by the COVID-19 pandemic. We explored relationships between drug use, COVID-19 testing, vaccination, and infection and found that PWUD were more likely, compared to non-users, to experience adversity brought about by the pandemic, such as housing insecurity and loss of income. This study also provides evidence that PWUD face disparities in COVID-19 testing access, and to the best of our knowledge, is one of the first to report lower odds of COVID-19 vaccination among PWUD in the Southern U.S. compared to non-using peers. While there were no significant differences in the proportions of those who self-reported ever being tested for COVID-19 by drug use, PWUD were more likely to face difficulties accessing testing. Interestingly, PWUD, compared to non-users, were less likely to self-report ever testing positive. However, SARS-CoV-2 positivity during the study tended to be more frequent among PWUD than non-users. Importantly, PWUD had lower odds of being vaccinated compared to non-users after adjustment for covariates. These findings highlight the need for improved efforts tailored to PWUD to promote better access to and utilization of testing and vaccination during the COVID-19 pandemic and future crises.
Testing for active viral disease is a cornerstone of contagion containment strategies. With one in six participants who had never been tested prior to participation in this study more than a year into the pandemic, understanding barriers to testing is critical to increasing testing uptake. Our data show that PWUD, more so than non-users, had tried to get tested for COVID-19 but were unsuccessful, were less confident in the accuracy of a negative result, and felt it would be difficult to get needed healthcare if positive. Altogether this indicates that PWUD may have faced a lack of access to testing and were discouraged from being tested due to a perceived lack of accuracy of the results and concerns about healthcare access. Distrust in the medical and research systems due to breaches of trust, mistreatment, and disclosure of protected health information in PWUD could also play a role in discouragement from COVID-19 testing [44]. Our findings agree with those in the literature that found COVID-19 testing was not broadly accessed by drug users and other marginalized populations [45]. However, most studies were conducted mainly in injection drug users [45, 46], and found that less than a third had ever been tested [47]. Our study differs from this literature in that a very small proportion of our participants reported injecting drugs (1.4% of the MASH cohort). Thus, we explored COVID-19 testing in relation to drug use of any type by any route of administration and indeed found disparities in difficulties accessing testing.
In terms of the potential increased risk for COVID-19 that PWUD face, Wang et al., found that a recent diagnosis of a substance use disorder (SUD) was associated with increased risk of COVID-19, hospitalization, and mortality [29]. Additionally, people with a recent SUD, compared to those without, had higher rates of morbidities related to worse COVID-19 outcomes (i.e., chronic lung and cardiovascular diseases, etc.). We found that PWUD were actually less likely to self-report prior COVID-19 illness, but we did not observe a significant difference in SARS-CoV-2 positivity via rt-PCR, although it tended to be more frequent among PWUD than non-users. We also found no associations between drug use and COVID-19 symptom severity or hospitalizations, but PWUD were more likely than non-users to expect worse COVID-19 outcomes. Our finding of no significant difference in SARS-CoV-2 positivity could be explained by the low rate of positivity observed; less than 3% tested positive. This could be due to the community-based study setting rather than a healthcare facility as well as the participants’ discomfort with the need to quarantine and a potential loss of income. Thus, participants may not have presented for testing when experiencing symptoms.
COVID-19 vaccines have been shown to be effective at preventing severe illness, hospitalization, and death due to COVID-19 [10]. Yet, we found that PWUD had 37% lower odds of being vaccinated compared to non-users after adjustment for covariates. Studies assessing self-reported injection drug use have also reported lower vaccination rates compared to non-users [18, 21]. It is unclear whether the lower vaccination rate among PWUD is due to poor access, vaccine hesitancy, or a combination of the two. However, we found that PWUD were more likely, compared to non-users, to report, “I don’t like needles”, “I’m not concerned about getting really sick from COVID-19”, “I’m concerned about side effects from the vaccine”, “I don’t think vaccines work very well”, “I don’t trust that the vaccine will be safe”, “I don’t believe the COVID-19 pandemic is as bad as some people say it is”, and, “I don’t know enough about how well a COVID-19 vaccine works”. Additionally, when unvaccinated participants were asked how likely they were to get a COVID-19 vaccine, PWUD were more likely than non-users to respond with, “don’t know”, “not too likely”, “not at all likely”, or, “definitely not”, suggesting that hesitancy could in fact, be a main driver of this disparity. Additionally, PWUD were more likely, compared to non-users, to have refused a vaccine in the past (COVID-19 vaccines among other vaccines). This supports the notion that drug use may be associated with hesitancy of other types of vaccines [22–26]. Although COVID-19 vaccines were, at the time, provided free-of-charge in the U.S., PWUD were more likely to report, “I don’t want to pay for it” than non-users, suggesting that immunization campaigns advertising vaccines as free regardless of insurance status [48], may not be reaching or be trusted by PWUD.
This research highlights the need for testing and immunization plans that are tailored to PWUD who are likely to face vaccine hesitancy and social barriers to testing, such as lack of transportation and technology, as well as competing priorities in the form of housing and food insecurity [49]. Therefore, effective strategies are needed to overcome testing barriers and vaccination hesitancy for this vulnerable population during the COVID-19 pandemic and future crises. Strengths of this study include the use of a large sample of underserved, low-income, racial/ethnic minority adults from Miami, Florida which experiences a high level of social vulnerability [37, 38] and our ability to confirm over 80% of all self-reported COVID-19 vaccinations with medical records. Additionally, as part of RADx-UP, future studies with larger sample sizes from cohorts across the nation are possible. Limitations for this research include the use of a sample that may not be representative of PWUD in Miami, self-report of substance use which is susceptible to recall bias and underreporting, and 12-month timeframe of drug use which may also contribute to recall bias. We do note, however, that previous studies have been successful in utilizing self-reported substance use data during the COVID-19 pandemic [18, 21, 47]. The cross-sectional design also does not allow for causality or temporality to be established (i.e., we cannot determine if drug use influenced COVID-19 outcomes, if the pandemic influenced drug use behaviors, or if the relationship is bidirectional). Finally, we were also unable to further stratify our sample by type of illicit drug used because of the small proportions (<1%) of participants who reported drug use other than cannabis or cocaine/crack.
Conclusion
PWUD presented with greater difficulties accessing COVID-19 testing and more concerns regarding testing accuracy and perceived risks of being tested. Compared to non-users, PWUD presented with greater vaccine hesitancy and significantly lower odds of COVID-19 vaccination. Testing and immunization plans that are tailored to the needs of PWUD and consider access, trust-building campaigns, and education may be needed during the COVID-19 pandemic and future crises.
Supporting information
S1 Checklist. STROBE statement—checklist of items that should be included in reports of cross-sectional studies.
https://doi.org/10.1371/journal.pone.0297327.s001
(DOC)
Acknowledgments
We would like to thank the Miami Adult Studies on HIV (MASH) cohort and Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) participants for their willingness to participate and important contributions to research, and the Borinquen Health Care Center in Miami, Florida for their service to the community and for providing space and resources. We appreciate our community partners and the guidance provided by our Community Advisory Board (CAB) and Scientific Advisory Board (SAB).
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