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Objective: People who use opioids are vulnerable to sleep disturbances due to a range of factors, including the substances they use and the various structural vulnerabilities they face. We aimed to understand the burden of sleep-related impairment and problems pertaining to sleep context and schedule among people who use opioids., Methods: We explored sleep quality and problems among a suburban sample of people who use opioids experiencing extensive structural vulnerabilities (N = 170). Participants reported their most urgent concern in the past week (e.g., sleep, drug use, housing), their sleep context, sleep problems, sleep schedules, and scores on the PROMIS Sleep-Related Impairment measure. We then quantified associations between Sleep-Related Impairment scores and sociodemographics and substance use., Results: Participants were primarily men (66%) and non-Hispanic Black (67%) with a mean age of 42 (SD: 12.1). Many experienced hunger (44%) and literal homelessness (40%). One-quarter (28%) reported that sleep was their most urgent concern in the past week. The most common problems when falling or staying asleep were mental health-related symptoms (81%) and pain/discomfort (32%). Literal homelessness (β = 2.2, 95% CI: 0.6, 3.7), hunger (β = 2.3, 95% CI: 1.0, 3.6), and frequent alcohol use (β = 1.5, 95% CI: 0.2, 2.7) were significantly associated with Sleep-Related Impairment scores., Conclusions: Homelessness and hunger are associated with sleep-related impairment in people who use opioids. Poor sleep quality, substance use, structural vulnerability, and mental health problems are all interrelated sources of functional impairment in this population. Interventions that address poverty as an underlying cause of sleep-related impairment and provide safe sleeping environments are needed., (Copyright © 2024 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Hepatitis C virus (HCV) infection and hazardous alcohol use are both preventable causes of morbidity and mortality among people who inject drugs (PWID). In the general population, hazardous alcohol is associated with a reduced likelihood of HCV treatment initiation. Less is known about the prevalence and impact of hazardous alcohol use on direct-acting antiviral (DAA) therapy initiation among PWID with active injection drug use., Methods: PWID were recruited via street outreach in Baltimore, Maryland, between 2018 and 2019 and were enrolled in a study cohort. Participants completed a study survey and underwent HCV testing. Self-reported DAA therapy initiation was evaluated at follow-up visits every six months. Hazardous alcohol use was determined based on an AUDIT-C score of ≥4 for men or ≥3 for women. Data were analyzed using multivariable logistic regression with generalized estimating equations., Results: Of the 720 PWID recruited, 291 had detectable HCV RNA, and only 134 were aware of their HCV infection. The mean (±standard deviation) age of those that were aware of their infection was 48.7 (±10.3) years, with a slight majority (53.0%) being male and predominantly African American (64.9%). The majority (80/134, 59.7%) met criteria for hazardous alcohol use. Only 16 (11.9%) PWID reported DAA therapy initiation within six months, and 20 (14.9%) reported it within 12 months of follow-up. Hazardous alcohol use (aOR = 1.23, 95% CI = 0.43-3.53) was not associated with DAA treatment initiation., Conclusions: There was a high prevalence of hazardous alcohol use, low rates of oral DAA therapy initiation, and no association between self-reported hazardous alcohol use and initiation of oral DAA therapy in our sample of PWID that were aware of their chronic HCV infection. Strategies to increase HCV treatment uptake in PWID with active drug use are urgently needed and should integrate alcohol and drug use evaluation and care.

Background: Over 107,000 people died in the United States (U.S.) from drug overdose in 2022, with over one million overdose deaths since 1999. The U.S. drug market is characterized by a highly toxic, unregulated, and rapidly changing supply. Understanding the extent of exposure to fentanyl among people who use drugs (PWUD) will guide public health interventions aimed to decrease overdose., Methods: We utilized baseline data from the Rhode Island Prescription and Illicit Drug Study, a randomized controlled trial of harm reduction-oriented interventions for PWUD in Rhode Island from 2020 to 2023. We evaluated sociodemographic and drug use-related covariates and examined fentanyl presence in urine drug testing (UDT). We built a classification and regression tree (CART) model to identify subpopulations with the highest likelihood of fentanyl presence in UDT., Results: Among 446 participants, those with fentanyl present in UDT tended to be younger, non-Hispanic white, and had recently injected drugs ( p <0.05 for all). The CART analysis demonstrated a large variation in sample sub-groups' likelihood of fentanyl presence in UDT, from an estimated probability of 0.09 to 0.90. Expected recent fentanyl exposure was the most important predictor of fentanyl in UDT., Conclusions: Univariate analyses and CART modeling showed substantial variation in the presence of fentanyl in UDT among PWUD. Harm reduction services for people actively injecting drugs and drug checking programs based on capacity-building, empowerment, and targeted towards those not yet engaged in services are urgently needed to support PWUD in navigating the current volatile drug supply., Competing Interests: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome., (© 2024 The Authors.)

Background: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear., Methods: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers' understanding and utilization of the term 'harm reduction' emerged as a salient theme which we conducted secondary thematic analysis to further explore., Results: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to 'reducing harms of drug use' or 'harm reduction' as guiding their policy approach; the remainder did not invoke 'harm reduction' by name but highlighted relevant concepts like racial equity and 'public health approaches' as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the 'public,' businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements)., Conclusions: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Despite the widespread use of the phrase "harm reduction" and the proliferation of programs based on its principles during the current opioid epidemic, what it means in practice is not universally agreed upon. Harm reduction strategies have expanded from syringe and needle exchange programs that emerged in the mid-1980s primarily in response to the HIV epidemic, to include medication for opioid use disorder, supervised consumption rooms, naloxone distribution, and drug checking technologies such as fentanyl test strips. Harm reduction can often be in tension with abstinence and recovery models to address substance use, and people who use drugs may also hold competing views of what harm reduction means in practice. Street-based outreach workers are increasingly incorporated into harm reduction programs as part of efforts to engage with people more fully in various stages of drug use and nonuse., Method: This paper explores how peer outreach workers, called "members," in a street-based naloxone distribution program define and practice harm reduction. We interviewed 15 members of a street-based harm reduction organization in an urban center characterized by an enduring opioid epidemic. Inductive data analysis explored harm reduction as both a set of principles and a set of practices to understand how frontline providers define and enact them., Results: Analysis revealed that when members talked about their work, they often conceptualized harm reduction as a collection of ways members and others can "save lives" and support people who use drugs. They also framed harm reduction as part of a "path toward recovery." This path was complicated and nonlinear but pursued a common goal of life without drug use and its residual effects. These findings suggest the need to develop harm reduction programs that incorporate both harm reduction and recovery to best meet the needs of people who use drugs and align with the value systems of implementers., (© 2024. The Author(s).)

Background: As in much of the United States, there have been significant increases in overdose deaths among non-Hispanic Black and Hispanic/Latinx populations in Rhode Island over the past decade. Given the shifting dynamics of the overdose epidemic, there is an urgent need for focused interventions that address the specific needs of diverse communities. This study explores differences in drug use patterns, harm reduction behaviors and types and barriers to treatment by race and ethnicity. Methods: This study utilized baseline data from the Rhode Island Prescription and Illicit Drug Study (RAPIDS). We assessed sociodemographic characteristics, drug use patterns, harm reduction practices, treatment type, and barriers to treatment in a cross-sectional analysis of people who use drugs (PWUD), stratified by race and ethnicity (non-Hispanic white, non-Hispanic Black, non-Hispanic other race, and Hispanic). Chi-square tests of independence and ANOVA tests were used to identify statistically significant differences by race and ethnicity. Results: Among 509 participants, the median age was 43, and the majority were men (64%). Non-Hispanic Black participants reported significantly less regular use of unregulated opioids, such as heroin (10%) and fentanyl (12%), as compared to non-Hispanic white participants (39% and 33%, respectively). Non-Hispanic Black participants reported significantly less experience responding to overdoses: only 39% had ever administered naloxone and 34% had ever performed rescue breathing, as compared to 67% and 57% among non-Hispanic white participants, respectively. Despite significant differences in drug use patterns, there were few differences in harm reduction practices by race and ethnicity. Current treatment enrollment was highest among those who were non-Hispanic white (38%) and lowest among those who were non-Hispanic Black (7%). Conclusions: These findings suggest that there are differences in overdose response experience and treatment exposure between non-Hispanic Black PWUD and those belonging to other racial and ethnic groups, indicating a need for enhanced investment in overdose response education, naloxone distribution and treatment access for non-Hispanic Black PWUD.

Harm reduction and opioid treatment programs (OTPs) modified service delivery based on rapid changes to state and federal regulations during the COVID-19 pandemic. There is little evidence on how these regulations changed the delivery of medication for opioid use disorder and harm reduction services and whether certain regulations should be made permanent. This study explores how harm reduction OTPs across the United States leveraged changes in regulations and responded to impacts of COVID-19 to continue providing services and perspectives on future legislation that regulates their practice and practice sites. The COVID Harm Reduction and Treatment programs Survey study administered a survey that included closed-ended and free-response questions to 22 sites between August 2020 and January 2021. Program demographics and responses to survey items pertaining to site and service modifications were tabulated and proportions reported. A qualitative descriptive method was used to analyze free-response questions. All (100%) surveyed providers reported the need to modify their services. The majority (68%) reported an increase or no change in client volume; 68% reported increases in naloxone services and 77% reported increases in syringe services programs. Qualitative themes included (a) flexibility in reaching clients due to regulatory changes, (b) benefits and drawbacks of telehealth, and (c) increased vulnerabilities of their clients during the pandemic. Despite difficulties during the COVID-19 pandemic, harm reduction and OTP sites found that regulatory changes provided flexibility in service delivery and that they were better able to serve their clients. Future policies should bolster these sites to continue to provide low-barrier and high-quality services. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion-or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD)., Methods: We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach., Results: Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability., Conclusions: Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To examine experiences of intimate partner violence (IPV) screening among women who sell sex., Design: A qualitative descriptive study., Setting: Telephone interviews during the COVID-19 pandemic (June 2020 to October 2020)., Participants: Women aged 18 to 49 years who sold or traded sex for food, drugs, money, or shelter at least three times during the past 3 months before recruitment (N = 22)., Methods: We used individual, semistructured telephone interviews to collect data about participants' experiences with IPV and IPV screening during health care encounters. We used reflexive thematic analysis to examine these data., Results: We identified two overarching themes related to IPV screening experiences: Preferences for IPV Screening and Barriers to Disclosure of IPV Experiences. Participants described a preference for IPV screening done face-to-face with providers who show a genuine interest in their responses. Stigma was a barrier of IPV disclosure., Conclusion: Health care providers are a trusted safety net for disclosure of IPV experiences. Providing screening in a trauma-informed, nonstigmatizing manner may facilitate disclosure of IPV by women who sell sex. Future research among marginalized populations is needed to examine ways to address IPV in clinical settings with a harm reduction empowerment lens., Competing Interests: Conflict of Interest The authors report no conflicts of interest or relevant financial relationships., (Copyright © 2024 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background and Aims: People who inject drugs (PWID) are at risk for adverse outcomes across multiple dimensions. While evidence-based interventions are available, services are often fragmented and difficult to access. We measured the effectiveness of an integrated care van (ICV) that offered services for PWID., Design, Setting and Participants: This was a cluster-randomized trial, which took place in Baltimore, MD, USA. Prior to randomization, we used a research van to recruit PWID cohorts from 12 Baltimore neighborhoods (sites), currently served by the city's mobile needle exchange program., Intervention and Comparator: We randomized sites to receive weekly visits from the ICV (n = 6) or to usual services (n = 6) for 14 months. The ICV offered case management; buprenorphine/naloxone; screening for HIV, hepatitis C virus and sexually transmitted infections; HIV pre-exposure prophylaxis; and wound care., Measurements: The primary outcome was a composite harm mitigation score that captured access to evidence-based services, risk behaviors and adverse health events (range = 0-15, with higher numbers indicating worse status). We evaluated effectiveness by comparing changes in the composite score at 7 months versus baseline in the two study arms., Findings: We enrolled 720 cohort participants across the study sites (60 per site) between June 2018 and August 2019: 38.3% women, 72.6% black and 85.1% urine drug test positive for fentanyl. Over a median of 10.4 months, the ICV provided services to 734 unique clients (who may or may not have been cohort participants) across the six intervention sites, including HIV/hepatitis C virus testing in 577 (78.6%) and buprenorphine/naloxone initiation in 540 (74%). However, only 52 (7.2%) of cohort participants received services on the ICV. The average composite score decreased at 7 months relative to baseline, with no significant difference in the change between ICV and usual services (difference in differences: -0.31; 95% confidence interval: -0.70, 0.08; P = 0.13)., Conclusions: This cluster-randomized trial in Baltimore, MD, USA, found no evidence that weekly neighborhood visits from a mobile health van providing injection-drug-focused services improved access to services and outcomes among people who injected drugs in the neighborhood, relative to usual services. The van successfully served large numbers of clients but unexpectedly low use of the van by cohort participants limited the ability to detect meaningful differences., (© 2024 Society for the Study of Addiction.)

We assessed acceptability of nonoral HIV pre-exposure prophylaxis (PrEP) formulations among transgender women (TW) engaged in street-based sex work in Baltimore, Maryland. In a K -means cluster analysis, TW ( N =36) were partitioned into groups characterized by high interest in long-acting injectable PrEP only ( Injectable Enthusiasts , 36%), high interest in injectables and subdermal implants ( Long-Acting Acceptors , 36%), and low interest across PrEP formulations ( Non-Acceptors , 28%). TW's interest in novel PrEP agents varied widely across formulations (range: 22-66%) and clustered around numerous relational, occupational, and structural factors, highlighting the importance of availing multiple PrEP formulations for this impacted population., Competing Interests: No competing financial interests exist., (Copyright 2024, Mary Ann Liebert, Inc., publishers.)

Background: Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors., Methods: Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics., Results: Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model., Conclusions: Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Sherman has served as an expert witness in opioid litigation cases. The authors have no other financial interests/conflicts of interest to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The legal enforcement of drug possession is associated with a host of negative consequences for people who use drugs (PWUD), has demonstrated little effectiveness at curbing drug use, and has contributed to lasting financial, social, and health-related racial disparities in Black and Brown communities in the United States (U.S.). One policy alternative is reinvesting resources typically used for enforcing drug possession into health-promoting services such as drug treatment or harm reduction that can better serve the needs of PWUD than the criminal legal system. We sought to characterize the prevalence and correlates of national public support for this reinvestment in the U.S., Methods: A nationally representative sample of U.S. adults (N = 1,212) completed the Johns Hopkins COVID-19 Civic Life and Public Health Survey (wave three, fielded November 11-30, 2020). The outcome is support for reinvestment of resources spent on enforcing drug possession into health-promoting alternatives (i.e., drug treatment, harm reduction, housing support, or community-based resources). We measured potential correlates including socio-demographics and social/political attitudes, including political ideology (conservative, moderate, liberal) and racial resentment toward the Black community. Analyses accounted for complex survey weights., Results: Weighted prevalence of support for reinvestment of resources was 80 %. Multivariable logistic regression (controlling for confounders) showed that white respondents were more likely than Black (OR = 2.51, 95% CI = 1.08, 5.87) to favor reinvestment. Respondents with moderate (OR = 0.34, 95 % CI = 0.15-0.79) or conservative (OR = 0.21, 95 % CI = 0.09-0.50) political ideology (compared to liberal) and medium (OR = 0.26, 95 % CI = 0.09-0.74) or high (OR = 0.12, 95 % CI = 0.04-0.35) levels of racial resentment (compared to low) were less likely to support reinvestment., Conclusion: There is substantial national support for reinvesting resources into health-promoting alternatives, though political ideology and racial resentment temper support. Results can inform targeted messaging to increase support for moving drug policy from the criminal legal sphere toward public health., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Sherman is an expert witness in ongoing opioid litigation. The other authors do not have competing interests to declare., (Copyright © 2024. Published by Elsevier B.V.)

Background: Overdose prevention centers (OPCs) are being implemented in the United States as a strategy to reduce drug-related mortality and morbidity. Previous studies have suggested that people who use drugs (PWUD) with a history of criminal legal system (CLS) involvement (e.g. current probation/parole) are at greater risk of overdose but may also encounter significant barriers to OPC use. The objective of this study was to explore the association between willingness to use an OPC and probation/parole status in a sample of PWUD in Rhode Island., Methods: This study utilized data from the Rhode Island Prescription and Illicit Drug Study, which enrolled adult PWUD from August 2020 to February 2023. We used Pearson's chi-square and Wilcoxon rank-sum tests to assess bivariate associations between willingness to use an OPC and probation/parole status (current/previous/never), as well as other sociodemographic and behavioral characteristics. In multivariable Poisson analyses, we examined the association between willingness to use an OPC and probation/parole status, adjusting for key sociodemographic and behavioral characteristics., Results: Among 482 study participants, 67% were male, 56% identified as white, 20% identified as Hispanic/Latine, and the median age was 43 (IQR 35-53). Nearly a quarter (24%) had never been on probation/parole, 44% were not currently on probation/parole but had a lifetime history of probation and parole, and 32% were currently on probation/parole. Most participants (71%) reported willingness to use an OPC, and in both bivariate and multivariable analyses, willingness to use an OPC did not vary by probation/parole status. Crack cocaine use and lifetime non-fatal overdose were associated with greater willingness to use an OPC (all p < 0.05)., Conclusions: These data demonstrate high willingness to use OPC among PWUD in Rhode Island regardless of CLS-involvement. As OPCs begin to be implemented in Rhode Island, it will be imperative to engage people with CLS-involvement and to ensure access to the OPC and protection against re-incarceration due to potential barriers, such as police surveillance of OPCs., (© 2024. The Author(s).)

Background: Sex workers, those who trade sex for monetary or nonmonetary items, experience high rates of HIV transmission but have not been adequately included in HIV prevention and Pre-Exposure Prophylaxis (PrEP) adherence program development research. Community-empowered (C.E.) approaches have been the most successful at reducing HIV transmission among sex workers. Centering Healthcare (Centering) is a C.E. model proven to improve health outcomes and reduce health disparities in other populations, such as pregnant women, people with diabetes, and sickle cell disease. However, no research exists to determine if Centering can be adapted to meet the unique HIV prevention needs of sex workers., Objective: We aim to explain the process by which we collaboratively and iteratively adapted Centering to meet the HIV prevention and PrEP retention needs of sex workers., Methods: We utilized the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, Testing (ADAPT-ITT) framework, a model for adapting evidence-based interventions. We applied phases one through six of the ADAPT-ITT framework (Assessment, Decision, Adaptation, Production, Topical Experts, Integration) to the design to address the distinct HIV prevention needs of sex workers in Chicago. Study outcomes corresponded to each phase of the ADAPT-ITT framework. Data used for adaptation emerged from collaborative stakeholder meetings, individual interviews (n = 36) and focus groups (n = 8) with current and former sex workers, and individual interviews with care providers (n = 8). In collaboration with our community advisory board, we used a collaborative and iterative analytical process to co-produce a culturally adapted 3-session facilitator's guide for the Centering Pre-exposure Prophylaxis (C-PrEP +) group healthcare model., Results: The ADAPT-ITT framework offered structure and facilitated this community-empowered innovative adaptation of Centering Healthcare. This process culminated with a facilitator's guide and associated materials ready for pilot testing., Conclusions: In direct alignment with community empowerment, we followed the ADAPT-ITT framework, phases 1-6, to iteratively adapt Centering Healthcare to suit the stated HIV Prevention and PrEP care needs of sex workers in Chicago. The study represents the first time the first time Centering has been adapted to suit the HIV prevention and PrEP care needs of sex workers. Addressing a gap in HIV prevention care for sex workers, Centering PrEP harnesses the power of community as it is an iteratively adapted model that can be piloted and replicated regionally, nationally, and internationally., (© 2023. The Author(s).)

Background: Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription. We examined associations of daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO)., Methods: PWUO (N = 417) were recruited from Baltimore City and neighboring Anne Arundel County, Maryland, and surveyed on sociodemographic characteristics, structural vulnerabilities, healthcare access and utilization, substance use, and overdose experiences. Multivariable logistic regression was used to identify factors associated with self-reported co-use., Results: Participants were 46 years old on average, and predominantly Black (74%) males (62%). Daily co-use was reported by 22%. In multivariable analyses, odds of co-use were significantly higher among participants who did not have a high school degree/GED (adjusted odds ratio [aOR]: 1.71, 95% confidence interval [CI]: 1.02-2.88), endorsed receiving mental health treatment in the past 6 months (aOR: 2.13, 95% CI: 1.28-3.56), reported daily use of powdered cocaine (aOR: 3.57, 95% CI: 1.98-6.45), and synthetic cannabinoids (aOR: 3.11, 95% CI: 1.40-6.93). Odds of co-use were significantly lower among Black participants compared to white participants (aOR: 0.39, 95% CI: 0.19-0.82)., Conclusions and Scientific Significance: Clinicians working with PWUO or who prescribe BZDs or opioids should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose., (© 2023 The Authors. The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry (AAAP).)

The continued prevalence of xylazine in the illicit drug market has necessitated development of quick and simple methods for identification, including lateral flow immunoassays (also known as "test strips"), like those frequently used to detect fentanyl. This study explored the drug checking applicability of the first publicly available xylazine test strips (XTS) using four sub-studies: reproducibility (i.e., consistency of positive results in a highly-concentrated xylazine solution); limit of detection on a calibration curve of xylazine concentrations; cross-reactivity against 77 commonly encountered drugs, cutting agents, and other structurally similar compounds; and applicability for analyzing community-acquired samples-where 100 drug residue samples were analyzed using XTS, direct analysis in real time mass spectrometry (DART-MS), and gas chromatography tandem mass spectrometry (GC-MS/MS). XTS consistently detected xylazine at concentrations ≥2.5 μg/ml, and XTS results were reproducible. Sensitivity and specificity of XTS were calculated by comparing expected versus obtained results based on xylazine concentration of community-acquired samples measured by GC-MS/MS. XTS consistently detected xylazine in samples with concentration >2 μg/ml and yielded a sensitivity of 0.974, specificity of 1.00, and overall accuracy of 0.986. Cross-reactivity with lidocaine, a common cutting agent, and lack of XTS reactivity with other α 2 -agonists found in the illicit drug supply highlight the need to offer consumers comprehensive drug checking services that identify a range of substances and better inform them about drug contents., (© 2023 John Wiley & Sons Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior., Methods: We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti., Results: A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices., Conclusion: Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention., Competing Interests: Declaration of Competing Interest Dr. Sherman and Dr. Krawczyk are expert witnesses for plaintiffs in ongoing opioid litigation. The rest authors have nothing to declare., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: Treatment for opioid use disorder (OUD) with diacetylmorphine is an evidence-based form of drug treatment, but it is not available in the United States (US). Better understanding acceptability of treatment with injectable diacetylmorphine among people who use opioids (PWUO) in the US may expedite future initiatives designed to engage persons in this form of treatment should it become available. The purpose of this research is to examine factors associated with interest in treatment with injectable diacetylmorphine among a sample of PWUO in the US., Methods: Data are from a cross-sectional study of PWUO in Baltimore City, Maryland. Participants were given a brief description of treatment with injectable diacetylmorphine and then asked to rate their level of interest. We used Poisson regression with robust variance to assess factors associated with interest in treatment with injectable diacetylmorphine., Results: The average age of participants was 48 years, 41% were women, and most (76%) identified as non-Hispanic, Black. The most commonly used substances were non-injection heroin (76%), opioid pain relievers (73%), and non-injection crack/cocaine (73%). Two-thirds of participants (68%) indicated interest in treatment with injectable diacetylmorphine. Factors significantly associated with interest in injectable diacetylmorphine treatment included: having at least a high school education (adjusted prevalence ratio [aPR]: 1.23; 95% confidence interval [CI]: 1.04-1.45), not having health insurance (aPR: 1.23; 95% CI: 1.06-1.44), having ever overdosed (aPR: 1.20; 95% CI: 1.01-1.42), and past utilization of medications for opioid use disorder (aPR: 1.22; 95% CI: 1.01-1.47). Recent non-injection cocaine use was inversely associated with interest in treatment with injectable diacetylmorphine (aPR 0.80; 95% CI: 0.68-0.94)., Conclusion: The majority of participants reported interest in treatment with injectable diacetylmorphine. Given worsening trends in the addiction and overdose crisis in the US, treatment with injectable diacetylmorphine should be considered as another evidence-based option for treating OUD.KEY MESSAGESInterest in treatment with injectable diacetylmorphine was high among a sample of people who use opioids in the United States.Factors associated with increased interest in treatment with injectable diacetylmorphine included having at least a high school education, having ever overdosed, and not having health insurance.Past utilization of medications for opioid use disorder was associated with interest in treatment with injectable diacetylmorphine.

Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07-1.80; p  < .05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14-2.32; p  < .01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence.

Introduction: To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession through prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs; however, data evaluating effects on arrest are lacking. This study explores the possible impacts of Baltimore City's enactment of de facto decriminalization on arrests by race., Methods: Police and court records were used to explore the possible impacts of Baltimore City's de facto decriminalization on street arrests and (processed) arrests advancing through the courts among people who use drugs. Interrupted time series models were used to compare pre-policy (January 2018-March 2020) trends with post-policy (April 2020-December 2021) trends in arrests for possession of drugs/paraphernalia and estimate racial disparities in street arrests (Black versus other races). Analyses were performed in February-May 2022., Results: The policy was associated with a significant and immediate decline in street and processed arrests for possession, which was not seen for other crime categories. Although declines were concentrated in the Black community, disparities in arresting persisted after the policy., Conclusions: De facto decriminalization may be a promising strategy to reduce exposure to the carceral system, an established risk factor for overdose and other drug-related sequelae and a driver of racial disparities in the U.S. Further research is needed to elucidate the drivers of persisting racial disparities and disentangle policy effects from pandemic-related closures., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking., Methods: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS., Findings: Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS., Conclusion: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Transgender women who sell sex (TWSS) experience high rates of HIV acquisition. Antiretrovirals for pre-exposure prophylaxis (PrEP) represent an efficacious HIV prevention strategy. The social and structural factors affecting PrEP delivery amongst TWSS are underexplored in the literature. We conducted ethnographic research to examine how multilevel social and structural factors manifest in TWSS's lived experiences and affect PrEP delivery and use. Twenty-four transgender women were recruited from the SAPPHIRE cohort and completed interviews focused on barriers and facilitators to PrEP engagement in the context of street-based sex work. Stakeholder interviews (N = 7) were also conducted. Our findings suggest there are unique features of the risk environment that can collectively impede PrEP use among TWSS., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: The messages used to communicate about harm reduction are critical in garnering public support for adoption of harm reduction interventions. Despite the demonstrated effectiveness of harm reduction interventions at reducing overdose deaths and disease transmission, the USA has been slow to adopt harm reduction to scale. Implementation of evidence-based interventions has been hindered by a historical framing of drug use as a moral failure and related stigmatizing attitudes among the public toward people who use drugs. Understanding how professional harm reduction advocates communicate to audiences about the benefits of harm reduction is a critical step to designing persuasive messaging strategies., Methods: We conducted qualitative interviews with a purposively recruited sample of U.S. professional harm reduction advocates (N = 15) to examine their perspectives on which types of messages are effective in persuading U.S. audiences on the value of harm reduction. Participants were professionals working in harm reduction advocacy at national- or state-level organizations promoting and/or implementing harm reduction. Semi-structured interviews were audio-recorded, transcribed, and analyzed using a hybrid inductive/deductive approach., Results: Interviewees agreed that messages about the scientific evidence demonstrating the effectiveness of harm reduction approaches are important but insufficient, on their own, to persuade audiences. Interviewees identified two overarching messaging strategies they perceived as persuasive: using messages about harm reduction that align with audience-specific values, for example centering the value of life or individual redemption; and positioning harm reduction as part of the comprehensive solution to current issues audiences are facing related to drug use and overdose in their community. Interviewees discussed tailoring messages strategies to four key audiences: policymakers; law enforcement; religious groups; and the family and friends of people who use, or have used, drugs. For example, advocates discussed framing messages to law enforcement from the perspective of public safety., Conclusions: Interviewees viewed messages as most persuasive when they align with audience values and audience-specific concerns related to drug use and overdose death. Future research should test effectiveness of tailored messaging strategies to audiences using experimental approaches., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: Low public support impedes widespread adoption of harm reduction services in the U.S. There are growing efforts to implement integrated programs offering harm reduction services alongside other services for people who use drugs. We tested how messages depicting integrated programs influence audience attitudes about harm reduction., Methods: A nine-group randomized experiment (N=3,181) embedded in a national survey of U.S. adults tested how factual and narrative messages describing programs integrating harm reduction, addiction treatment, and/or other services to reduce overdose influenced respondents' attitudes about harm reduction, relative to a comparison message defining harm reduction. The survey was fielded from September 16 th to September28th, 2022 using the NORC Amerispeak probability-based online survey panel. The survey response rate was 74%. Measures included perceived effectiveness of standalone and integrated harm reduction programs, willingness to have a harm reduction program in the neighborhood or person using harm reduction services as a neighbor, and support for increasing government spending on harm reduction services., Results: 54.4% of respondents viewing the comparison message defining harm reduction reported that an integrated approach including harm reduction, addiction treatment, and other services is effective at reducing overdose, compared to 63.6%-69.1% of respondents viewing messages describing integrated programs (p<0.05). Messages depicting either standalone harm reduction or integrated programs lowered respondents' willingness to have a harm reduction program in their neighborhood, particularly when the messages depicted a Black person, versus a White person, benefiting from harm reduction., Conclusions: Messages depicting programs offering integrated services including but not limited to harm reduction may heighten audience endorsement of the effectiveness of such an approach but lower willingness to have a harm reduction program in the neighborhood., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Female sex workers ( FSWs) are vulnerable to a number of health issues, but often delay seeking health care due to structural barriers. Multiservice drop-in centers have been shown to increase FSW access to health services globally, but their impact on FSW in the United States is lacking. This study seeks to evaluate the effect of a community-level empowerment intervention (the multiservice drop-in SPARC center) on cumulative sexually transmitted infections (STIs) among FSW in a city in the United States., Methods: Between September 2017 and January 2019, 385 FSWs were recruited in Baltimore. Participants from areas served by SPARC were recruited to the intervention; other areas of Baltimore were the control. Follow-up occurred at 6, 12, and 18 months. The primary outcome is cumulative STI (ie, positive gonorrhea or chlamydia test at any follow-up). We tested effect modification by condomless sex with paying clients reported at baseline. Logistic regressions with propensity score weighting were used to estimate intervention effect, accounting for loss to follow-up, with bootstrap confidence intervals., Results: Participants completed 713 follow-up study visits (73%, 70%, 64% retention at 6, 12, and 18 months, respectively). Baseline STI prevalence was 28% and cumulative STI prevalence across follow-ups was 26%; these both did not differ between control and intervention communities in bivariate analyses. After adjusting for covariates, FSW in the intervention had a borderline-significant decrease in odds of cumulative STI compared with control (odds ratio, 0.61, P = 0.09 ) . There was evidence of effect modification by baseline condomless sex, such that FSW in the intervention who reported condomless sex had lower odds of cumulative STI compared with FSW in the control community who also reported baseline condomless sex (odds ratio, 0.29; P = 0.04)., Conclusions: Results demonstrate the value of a low-barrier, multiservice model on reducing STIs among the highest-risk FSW.Clinical Trial Number: NCT04413591., Competing Interests: Conflict of Interest: S.G.S. is an expert witness in ongoing opioid litigation. The other authors have no competing interests to declare., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

COVID-19 exacerbated health disparities, financial insecurity, and occupational safety for many within marginalized populations. This study, which took place between 2019 and 2022, aimed to explore the way in which sex workers ( n = 36) in Chicago were impacted by COVID-19. We analyzed the transcripts of 36 individual interviews with a diverse group of sex workers using thematic analysis. Five general themes emerged regarding the detrimental impact of COVID-19 on sex workers: (1) the impact of COVID-19 on physical health; (2) the economic impact of COVID-19; (3) the impact of COVID-19 on safety; (4) the impact of COVID-19 on mental health; and (5) adaptive strategies for working during COVID-19. Participants reported that their physical and mental health, economic stability, and safety worsened due to COVID-19 and that adaptive strategies did not serve to improve working conditions. Findings highlight the ways in which sex workers are particularly vulnerable during a public health crisis, such as COVID-19. In response to these findings, targeted resources, an increased access to funding, community-empowered interventions and policy changes are needed to protect the health and safety of sex workers in Chicago.

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID (N = 211) in Baltimore, Maryland always asking new clients about their HIV/STI status. Most WSSID were non-Hispanic White (73%) and 74% reported current homelessness. 50% of WSSID reported always asking new clients about their HIV/STI status. Experiencing depressive symptoms (adjusted odds ratio [aOR]: 0.53; 95% confidence interval [CI]: 0.29, 0.96) and having condomless sex with clients (aOR 0.31; 95% CI: 0.17, 0.57) were inversely associated with WSSID always asking new clients about their HIV/STI status. Recent entry into sex work (aOR 2.99; 95% CI: 1.30, 6.87) was positively associated with always asking new clients about their HIV/STI status. Enhancing HIV/STI communication in combination with engagement in other risk mitigation strategies may decrease disease incidence among WSSID., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: The aim of the study was to examine how female sex worker's motivations, desires, intentions and behaviours towards childbearing and childbearing avoidance inform their contraceptive decision-making. We explored the influence of social determinants of health in the domains of social context (sexual partners and experiences of violence), healthcare access, economic instability on the contraceptive decision-making process., Design: We conducted a qualitative descriptive study informed by Miller's Theory of Childbearing Motivations, Desires and Intentions through the lens of social determinants of health., Methods: Participants were recruited from a parent study, EMERALD, in July-September, 2020. Data were collected from 22 female sex workers ages 18-49 using semi-structured 45 to 60-min audio-recorded interviews and transcribed verbatim. Theory guided the development of the study's interview guide and thematic analytic strategy., Results: Five themes emerged related to contraceptive decision-making: Motivations (value of fatherhood), Desires (relationships with love), Intentions and Behaviours (drugs overpower everything, contraceptive strategies and having children means being a protector). Women's contraceptive decision-making often included intentions to use contraception. However, social determinants such relationships with clients and intimate partners, interpersonal violence and challenges accessing traditional health care offering contraceptive services often interfered with these intentions and influenced contraceptive behaviours., Conclusion: Women's contraceptive decision-making process included well-informed desires related to childbearing and contraceptive use. However, social determinants across domains of health interfered with autonomous contraceptive decision-making. More effort is needed to examine the influence of social determinants on the reproductive health of this population., Impact: Findings from this study build on existing research that examines social determinants impacting reproductive health among female sex workers. Existing theoretical frameworks may not fully capture the influence constrained reproductive autonomy has on contraceptive decision-making. Future studies examining interpersonal and structural barriers to contraception are warranted., Patient or Public Contribution: The parent study, EMERALD, collaborated with community service providers in the study intervention., (© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in nine states and the District of Columbia. We used logistic regression to identify correlates of recent HIV testing among PWID (n = 289). Most (52.9%) PWID reported having been recently tested for HIV. Factors associated with recent HIV testing included: having attended college [adjusted odds ratio (aOR) 2.32, 95% confidence interval (95% CI) 1.32-4.10], weekly hunger (aOR 2.08, 95% CI 1.20-3.60), crystal methamphetamine injection (aOR 2.04, 95% CI 1.05-3.97), and non-metropolitan residence (aOR 0.33, 95% CI 0.13, 0.88). Findings suggest HIV testing initiatives should be expanded during times of crisis, such as global pandemics., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises., Objective: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19., Methods: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing., Results: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing., Conclusions: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment., (© 2023. The Author(s).)

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW ( n  = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e. , low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV , high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression , post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV . Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

Background: The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police., Methods: A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time., Results: One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13-3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13-3.17), recent arrest (aOR = 1.51; 95% CI 1.01-2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24-3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63-3.71) were significantly independently associated with recent sex with police., Conclusions: Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose-and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES., (© 2023. The Author(s).)

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results : Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions : Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.

Background: During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission., Methods: We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug treatment providers located in nine states and the District of Columbia. We assessed if solitary drug use had increased since the start of COVID-19. Associations between increased solitary drug use and sociodemographic characteristics, drug use characteristics, and COVID-19 prevention behaviors were examined using multiple logistic regression., Results: Half the sample identified as men (52.7%), White (49.7%), and single (49.3%). The average age was 43.2 (SD:11.8) years. Two-thirds (66.8%) recently injected drugs. 44% reported increased solitary drug use since COVID-19. Significant correlates of increased solitary drug use included being single (adjusted Odds Ratio [aOR]=1.99, 95% Confidence Interval [CI]: 1.33, 2.98), increasing drug use (aOR=2.74, 95% CI: 1.72, 4.37), using more in private locations (aOR=1.91, 95% CI: 1.34, 2.72), and social distancing behaviors (aOR=1.31, 95% CI: 1.11, 1.54). Experiencing homelessness (aOR=0.45, 95% CI: 0.31, 0.65) and identifying as a sexual minority (aOR=0.53, 95% CI: 0.31, 0.93) were associated with being less likely to increase solitary drug use., Conclusions: Solitary drug use increased during the COVID-19 pandemic. Increases in solitary drug use, in the context of a drug market increasingly permeated by fentanyl, indicates an urgent need for comprehensive harm reduction interventions to reduce overdose mortality., Competing Interests: Declarations of Interests The authors have no potential conflicts of interest to report., (Copyright © 2022. Published by Elsevier B.V.)

Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to healthcare utilization means that WWUD may have diminished accessing to COVID testing. The CARE (COVID Action Research Engagement) study first examines predisposing and enabling factors that predict COVID testing uptake over six months (baseline, 3-, and 6-month follow-up) among a cohort of WWUD (N = 250) in Baltimore, Maryland, providing a nuanced and holistic understanding of how to meaningfully engage WWUD in COVID testing. Then, point-of-care COVID testing will be implemented on a mobile outreach van affiliated with a local community-based organization primarily serving WWUD; anonymous surveys of mobile outreach guests (N = 100) will assess feasibility and acceptability of this integrated testing. The study is grounded in the Behavioral Model for Vulnerable Populations and the Theoretical Framework of Acceptability. We hypothesize that point-of-care COVID testing integrated into a low-barrier harm reduction service, such as a mobile outreach program, will be an enabling environment for COVID testing uptake in part by reducing structural impediments to testing and will be highly feasible and acceptable to participants. Strengths, limitations, and plans for results dissemination are discussed., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Sherman is an expert witness on ongoing opioid litigation. This does not alter our adherence to PLOS ONE policies on sharing data and materials.”, (Copyright: © 2022 Tomko 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.)

Introduction: Despite decades of empirical research in the US and internationally documenting the benefits of implementing syringe services programs (SSPs), their implementation may be controversial in many jurisdictions. Better understanding how research evidence is applied during SSP implementation processes may enable the public health workforce to advocate for program scale up. This study explores applications of research evidence during processes to acquire approvals for SSP implementation in rural counties in Kentucky., Methods: In-depth interviews were conducted among eighteen stakeholders (e.g. health department directors, SSP operators) involved in SSP implementation in rural Kentucky counties. Stakeholders were asked to describe the contexts surrounding SSP implementation processes. Interviews were transcribed and analysed for applications of research evidence. Research evidence-related quotes were subsequently categorised based on the typologies for applications of research evidence developed by Weiss et al. (instrumental, conceptual, and symbolic) and a fourth category for instances when research evidence was not used., Results: Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support. SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based. Participants reported symbolic research evidence applications to justify pre-existing attitudes and beliefs about meeting the public health needs of people who inject drugs. Lastly, in some instances, research evidence was met with scepticism and an unwillingness to consider its merits., Conclusion: Applications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature. Better understanding the diversity of ways in which research evidence may be employed during SSP implementation processes may support efforts to improve the public health of people who inject drugs.Key messagesApplications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature.Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support.SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based.

Introduction: People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs., Methods: Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory., Results: Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients., Discussion: MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

Background: Drug overdose deaths remain the primary cause of unintentional injuries in the United States. We examined the validity of a fentanyl test strip (FTS) in detecting fentanyl and its related analogs in water-based illicit drug solutions., Methods: Illicit drugs obtained from law enforcement (N = 343) were tested using a lateral flow chromatographic immunoassay FTS (BTNX Rapid Response) and Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) at a clinical chemistry laboratory in Baltimore, Maryland., Results: The FTS assay detected fentanyl at 200 ng/ml in water, and 13 additional fentanyl analogs, but failed to detect carfentanil and furanyl fentanyl at or below 1000 ng/ml. Overall sensitivity and specificity for detecting fentanyls was 98.5 % and 89.2 %; and the false negative and positive rate was 1.5 % and 10.9 %. False negatives (n = 2) occurred in fentanyl and a fentanyl precursor. False positives (n = 23) occurred in the presence of other illicit drugs and compounds (56.5 %) or when fentanyls were present below 40 ng/ml (43.5 %). False positive/negative rates remained low when testing cocaine and prescription opioid (PO) samples., Conclusions: FTS is a valid drug checking tool, however, rapid immunoassays and other drug checking instruments that can detect a wider range of fentanyl analogs including carfentanil need to be prioritized to minimize accidental exposure to the full spectrum of fentanyls., Competing Interests: Conflict of Interest JNP is a consultant for a cooperative grant between Harvard Medical School and the Food and Drug Administration (U01FD00745501). SGS is an expert witness for plaintiffs in opioid litigation., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES., Methods: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time., Results: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06))., Conclusions: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population., Competing Interests: Declarations of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Sherman has served as an expert witness in opioid litigation cases. The authors have no other financial interests/conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier B.V.)

Drug overdose remains a leading cause of death in the US, and the majority of opioid overdose fatalities involve fentanyl. This study aims to measure the degree of concordance between self-reported and biologically tested exposure to fentanyl. We conducted a cross-sectional analysis using survey and urinalysis data collected between 2019 and 2020 from Anne Arundel County, Maryland. Among urinalysis participants (n =113), 30% reported daily fentanyl use, and among this group, only 54% had a fentanyl-positive result. Cohen Kappa between self-reported and biologically detected fentanyl use was 0.26, indicating minimal agreement between the 2 markers. Limitations to interpreting self-reported and urinalysis data are discussed in this report., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 American Society of Addiction Medicine.)

Background: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men's selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland., Methods: Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors., Results: Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97-0.99, p &lt; 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81-7.37, p &lt; 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05-3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02-3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex., Conclusions: Synergistic sources of social and structural marginalization-from sexuality to hunger, homelessness, and injection drug use-are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO., (© 2022. The Author(s).)

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality., Objective: This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties., Methods: From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement., Results: Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries., Conclusions: The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity., (© 2022. The Author(s).)

Background: Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic., Methods: We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs., Results: We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services., Conclusions: In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD., (© 2022. The Author(s).)

Background: Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one's environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience., Methods: WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response., Results: Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and "self-medication" through substance use was common absent other perceived options for help., Conclusions: External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS' ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society's stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities., (© 2022. The Author(s).)

Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social cohesion and CCC among cisgender WES (n = 384) in Baltimore, Maryland using stratified logistic regression, controlling for potential confounders. Forty-five percent of WES experienced CCC. SM-WES reported significantly higher social cohesion than heterosexual WES. The relationship between social cohesion and CCC differed by sexual orientation. Among SM-WES, higher social cohesion was independently associated with decreased odds of experiencing CCC, controlling for food insecurity, crack use, police harassment, and method of finding clients. Among heterosexual WES, no significant association was found. Ongoing research and practice with WES should (1) collect sexual orientation data to allow for deeper understanding and tailored interventions, (2) leverage and nurture social cohesion and (3) tailor interventions to populations with attention to sexual orientation., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, including a community forum, key informant interviews with providers, and focus group discussions with FSW. FSW and providers acknowledged challenges to building rapport and establishing continuity in care settings. FSW reported low PrEP awareness, with high interest once aware. FSW and providers reported uptake barriers including perceived financial issues, lack of PrEP awareness, and mistrust of the pharmaceutical industry. Concerns were raised about substance use and daily PrEP adherence. Developing a tailored PrEP intervention for FSW necessitates multiple perspectives (e.g. FSW, service providers). Resumen La profilaxis preexposición (PrEP) es un componente vital de la prevención integral del VIH para las trabajadoras sexuales (TSF). En los Estados Unidos, hay pocas intervenciones de PrEP dirigidas a las TSF, quienes experiencian un riesgo elevado de contraer el VIH. Se realizó una investigación formativa para informar a PEARL (Promoción del empoderamiento y la reducción de riesgos), una intervención de PrEP para TSF en Baltimore, MD-la cual incluyó un foro comunitario, entrevistas con proveedores de servicios a las TSF y discusiones entre grupos focales de TSF. TSF y proveedores de servicio reconocieron los retos de mantener buenas relaciones y establecer continuidad en los servicios de salud. TSF exhibieron conocimiento limitado sobre la PrEP, pero expresaron gran interés en la PrEP después de estar informadas. TSF y los proveedores de servicios hablaron de barreras aceptando a la PrEP, incluyendo problemas financieros percibidos, falta de conocimiento sobre la PrEP y desconfianza en la industria farmacéutica. Se expresaron preocupaciones sobre el uso de sustancias y la adherencia diaria a la PrEP. El desarrollo de una intervención de PrEP personalizada para TSF requiere varias perspectivas (por ejemplo, TSF, proveedores de servicios)., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Intervetions are urgently needed to reduce the trajectory of the US opioid overdose epidemic, yet implementation is often hampered by resistance or opposition from key community stakeholders. While businesses are economically and physically impacted by the opioid epidemic, they are rarely engaged in efforts to reduce its impact. The establishment of overdose prevention sites (OPS) is being discussed throughout many US jurisdictions with limited attention to the potential positive role of businesses in that process. We surveyed business owners and employees of businesses located in neighborhoods with concentrated drug markets. The study's primary aim was to examine their attitudes to locally-placed OPS. An iterative, two-phase sampling strategy was used to identify recruitment zones. In person (December 2019-March 2020) and telephone-based (April-July 2020) surveys were administered to distinct business owners and employees (N = 149). Sixty-five percent of participants supported OPS in their neighborhood and 47% had recently witnessed an overdose in or around their workplace. While 70% had heard of naloxone, and 38% reported having it on the premises. Correlates of supporting an OPS locally included living in the same neighborhood as work (adjusted odds ratio (aOR) 1.99, 95% confidence intervals (CI): 1.30-3.05); having a more positive attitude towards people who use drugs (aOR 1.33, 95% CI: 1.13-1.58); and having recently seen an overdose in/around the workplace (aOR 2.86, 95% CI: 1.11-7.32). Lack of support being an owner (aOR 0.35, 95% CI: 0.15-0.83). These data indicate the extent to which businesses are directly impacted by the opioid epidemic and the power of personal experience in shaping OPS support in advocacy efforts., (© 2022. The Author(s).)