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Background Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services. Objective We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use. Design Rural Opioids Initiative (ROI) — cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018–March 2020); National Survey on Family Growth (NSFG) — nationally-representative U.S. household reproductive health survey (2017–2019). Participants Women aged 18–49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses. Main Measures Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations. Key Results Of 855 women in the ROI, 36.8% (95% CI 33.7–40.1, unweighted) and 38.6% (95% CI 30.7–47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08–2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95–1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96–1.82]) that did not meet the threshold for statistical significance. Conclusion WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.

IntroductionTimely descriptions of HIV service characteristics and their evolution over time across diverse settings are important for monitoring the scale-up of evidence-based program strategies, understanding the implementation landscape, and examining service delivery factors that influence HIV care outcomes.MethodsThe International epidemiology Databases to Evaluate AIDS (IeDEA) consortium undertakes periodic cross-sectional surveys on service availability and care at participating HIV treatment sites to characterize trends and inform the scientific agenda for HIV care and implementation science communities. IeDEA’s 2020 general site assessment survey was developed through a consultative, 18-month process that engaged diverse researchers in identifying content from previous surveys that should be retained for longitudinal analyses and in developing expanded and new content to address gaps in the literature. An iterative review process was undertaken to standardize the format of new survey questions and align them with best practices in survey design and measurement and lessons learned through prior IeDEA site assessment surveys.ResultsThe survey questionnaire developed through this process included eight content domains covered in prior surveys (patient population, staffing and community linkages, HIV testing and diagnosis, new patient care, treatment monitoring and retention, routine HIV care and screening, pharmacy, record-keeping and patient tracing), along with expanded content related to antiretroviral therapy (differentiated service delivery and roll-out of dolutegravir-based regimens); mental health and substance use disorders; care for pregnant/postpartum women and HIV-exposed infants; tuberculosis preventive therapy; and pediatric/adolescent tuberculosis care; and new content related to Kaposi’s sarcoma diagnostics, the impact of COVID-19 on service delivery, and structural barriers to HIV care. The survey was distributed to 238 HIV treatment sites in late 2020, with a 95% response rate.ConclusionIeDEA’s approach for site survey development approach has broad relevance for HIV research networks and other priority health conditions.

Depression is associated with suboptimal HIV care outcomes. Little is known about the extent to which the prevalence of depressive symptoms varies across the HIV care continuum. Also, the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms in PLWH remains poorly understood. We analyzed cross-sectional data from 12,507 PLWH at enrollment in International epidemiology Databases to Evaluate AIDS (IeDEA) Cameroon between 2016 and 2020. Recent depressive symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2). A score of three or greater on the PHQ-2 was considered indicative of likely major depressive disorder. We estimated the prevalence of depressive symptoms across three stages of HIV care: those not yet on antiretroviral therapy (ART), recent ART initiators (ART initiation ≤ 30 days prior), and ART users (ART initiation > 30 days prior). Adjusted prevalence differences (aPD) of depressive symptoms were estimated comparing recent ART initiators and ART users. Disclosure and gender were examined as effect measure modifiers of the relationship between HIV care stage and depressive symptoms. The prevalence of depressive symptoms was 11.9%, 22.0%, and 8.7% among PLWH not yet on ART, recent ART initiators, and ART users, respectively. ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD − 0.09 [95% CI − 0.11, − 0.08]). Neither gender nor HIV disclosure modified the effect measure of the relationship between HIV care stage and depressive symptoms. Depressive symptoms were commonly reported among this group of PLWH and were associated with recent ART initiation. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.

Lack of social support and sex work stigma may hinder STI/HIV prevention for female sex workers (FSW). We explored the prevalence and associations between sex work stigma and social support with sexual behaviors in Malawi. In 2017, 150 HIV-negative, venue-based FSW completed a behavioral survey containing sex work stigma items that captured internalized stigma, isolation from family and friends, fear of disclosure, and health care discrimination, as well as emotional/informational, tangible, affectionate, and positive interaction social support. Linear binomial regression models were used to estimate prevalence differences comparing the probability of inconsistent condom use and substance use before sex by social support and stigma. A majority (93%) reported sex work-related internalized stigma. About 50% reported family or friend isolation. Social support was high (mean index: 86.53). Inconsistent condom use and substance use before sex had little to no association with stigma and social support. FSW in Lilongwe largely internalize stigma and experience isolation from family and friends yet have high levels of social support. Large-scale evaluations should investigate the role of stigma and social support in STI/HIV prevention for FSW.

Persistent stigma remains a crucial barrier to HIV prevention and treatment services among people who use drugs (PWUD), particularly for those living with or at-risk for HIV. This scoping review examines the current state of science with regard to approaches for measuring and addressing stigma within HIV interventions among PWUD.Sixteen studies fit the inclusion criteria for this review. Half the studies originated within the USA, and the remaining represented four different regions. Within these studies, stigma was measured using various quantitative, qualitative, and mixed methods. The studies primarily focused on HIV stigma, including value-based judgments, anticipated stigma, and perceived stigma domains. Information-based and skills building approaches at the individual level were the most common for the stigma reduction interventions. Adoption of systematic evaluations is needed for measuring stigma, including intersectional stigma, within HIV interventions among PWUD. Future studies should focus on developing multilevel intersectional stigma reduction interventions for PWUD with and at-risk for HIV globally.

Background Naloxone is a life-saving and easy-to-administer opioid antagonist medicine. Despite naloxone's legality in Ohio, unintentional drug overdoses remain the leading cause of injury deaths. Understanding the barriers and facilitators to naloxone's community uptake will help inform interventions to increase the awareness, accessibility, and use of naloxone. Our study aimed to identify barriers and facilitators to opioid overdose reversal uptake to inform community-driven interventions. Methods We conducted in-depth interviews and focus group discussions with people who use opioids, community members, and key stakeholders in Central Ohio from February 2019 to October 2019. We used qualitative thematic analysis to identify barriers and facilitators to the uptake of naloxone in a community setting. We classified barriers and facilitators to community naloxone uptake using the socio-ecological model's exterior levels – organizational, community, and societal. Results A total of 47 Central Ohio residents participated in five focus group discussions and fifteen in-depth interviews. Community members (n = 23), harm reduction service providers (n = 4), and religious organizational staff (n = 5) participated in focus group discussions ranging in size from 4 to 10 participants. We conducted in-depth interviews with law enforcement officers (n = 3), pharmacists (n = 2), and people who use opioids (n = 10). At the organizational level, access to naloxone, lack of resources, organizational stigma, and misinformation emerged as barriers. In contrast, naloxone awareness and availability, safe spaces for people who use opioids, and organizational collaboration emerged as facilitators. We identified the following community-level barriers: naloxone misinformation, knowledge, awareness, and substance use stigma. Perspectives on collective responsibility to administer naloxone was identified as both a barrier and facilitator. At the societal level, despite Ohio's Good Samaritan law and the legality of naloxone, poor communication of naloxone laws was a prevalent barrier to naloxone uptake, as was the burden of law enforcement to respond to and manage overdoses. Conclusions Community-based interventions that develop collaborations among local organizations to provide naloxone information, training, and distribution may address prominent barriers to naloxone uptake and reduce the current burden of law enforcement to respond to overdoses. Future interventions should also dispel naloxone misinformation, substance-use stigma, and confusion about the legal consequences of administering naloxone.

Rural communities bear a disproportionate share of the opioid and methamphetamine use disorder epidemics. Yet, rural people who use drugs (PWUD) are rarely included in trials testing new drug use prevention and treatment strategies. Numerous barriers impede rural PWUD trial engagement and advancing research methods to better retain rural PWUD in clinical trials is needed. This paper describes the Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-RThe PROUD-RThe protocol was approved by a central Institutional Review Board (University of Utah). Results of the study will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders.NCT03885024.

OBJECTIVE Vietnam, Indonesia, and Ukraine have major burdens of IDU and HIV. We estimated the prevalence of depressive symptoms at baseline among people living with HIV who inject drugs, evaluated associations between depression at baseline and 12-month HIV care outcomes and medication-assisted treatment (MAT), and evaluated the study intervention effect by baseline depression subgroups. DESIGN HPTN 074 was a randomized study. The study intervention included psychosocial counseling, systems navigation, and antiretroviral treatment (ART) at any CD4+ cell count. METHODS Moderate-to-severe depression was defined as a Patient Health Questionnaire-9 score of 10 or above. ART and MAT were self-reported. Eligibility criteria were: 18-60 years of age, active IDU, and viral load of at least 1000 copies/ml. Adjusted probability differences (aPD) were estimated using inverse-probability weighting. RESULTS A total of 502 participants enrolled from April 2015 to June 2016. Median age was 35 years; 85% identified as men. Prevalence of baseline moderate-to-severe depression was 14% in Vietnam, 14% in Indonesia, and 56% in Ukraine. No evident associations were detected between baseline depression and ART, viral suppression, or MAT at 12-month follow-up. The study intervention improved the proportions of people who inject drugs achieving 12-month viral suppression in both the depressed [intervention 44%; standard of care 24%; estimated aPD = 25% (95% confidence interval: 4.0%, 45%)] and nondepressed subgroups [intervention 38%; standard of care 24%; aPD = 13% (95% confidence interval: 2.0%, 25%)]. CONCLUSION High levels of depressive symptoms were common among people living with HIV who inject drugs in Ukraine but were less common in Vietnam and Indonesia. The study intervention was effective among participants with or without baseline depression symptoms.

Background Prior to the widespread availability of antiretroviral therapy (ART), men living with human immunodeficiency virus (HIV) with urethritis had increased concentrations of HIV in semen. This study aims to better evaluate HIV shedding in men with urethritis receiving ART, and its implications for the cure of HIV. Methods Men living with HIV with urethritis taking ART ≥12 weeks were enrolled at a sexually transmitted infections clinic in Lilongwe, Malawi. Study follow-up included visits at 1, 2, 4, 8, 12, 24, 36, and 48 weeks after urethritis diagnosis and treatment. Matched blood and semen samples were collected at all visits, and all additional episodes of urethritis were followed with extra visits 1, 2, and 4 weeks after treatment. Results There were 111 men enrolled in the study between January 2017–March 2019, and 77 (69%) were suppressed in the blood ( Conclusions An HIV cure requires the elimination of HIV from every body compartment, but available ART does not currently accomplish this. Our study highlights the male genital tract as a local source of HIV that can be reversibly activated. A better understanding of this phenomenon is important to advance the HIV cure field.

BACKGROUND: People who inject drugs (PWID) in rural areas of the United States have had limited access to syringe service programs (SSP). Rural SSP have recently surged, but accompanying research is lacking about PWID utilization, barriers, and preferences for SSP design and how those preferences vary by gender. METHODS: Interviewer-administered surveys elicited information about utilization, barriers, and preferences for SSP design from 234 PWID recruited using respondent-driven sampling in Appalachian, Kentucky. Gender differences among reported barriers to utilizing SSP and preferences for program design were explored using Mantel-Haenszel chi-square tests. RESULTS: Overall, 49% of PWID had ever utilized an SSP. The most common reasons for not utilizing an SSP were lack of awareness (23%), fear of being seen or disclosing drug use (19%), and lack of need (19%). The most preferred SSP design was located within a health department (74%) and operating during afternoon hours (66%). Men were more likely than women to prefer SSP in health departments (80% vs. 65%, p = 0.01), while more women than men preferred staffing by health department personnel (62% vs. 46%, p = 0.02). Women were less likely to favor evening hours (55% vs. 70%, p = 0.02). Fewer women wanted SSP nurses (78% vs. 90%, p = 0.01), social workers (11% vs. 24%, p = 0.01), or people who use drugs (20% vs 34%, p = 0.02) to staff SSP. CONCLUSIONS: Despite recent scale-up, SSP in Appalachia remain under-utilized. PWID were open to a range of options for SSP design and staffing, though there were variations by gender. Implementation research that identifies best strategies for tailored SSP scale-up in rural settings should be considered.

Background: Emergency medical services (EMS) personnel frequently encounter occupational factors that increase the risk of poor sleep and stress. The national prevalence of poor sleep and stress in...

BACKGROUND AND OBJECTIVE: Drug use type and frequency may affect Anti-Retroviral Therapy (ART) uptake for HIV-infected people who inject drugs (PWID). This paper assesses the association between self-reported baseline drug use and ART among HIV-infected PWID in Indonesia, Ukraine and Vietnam. METHODS: Data on self-reported baseline drug use and ART among HIV-infected PWID at the 26- and 52-week follow-ups were extracted from the HIV Prevention Trials Network (HPTN) 074, a randomized, controlled vanguard study to facilitate HIV treatment for PWID in Indonesia, Ukraine, and Vietnam. Multivariable logistic regression models were fit by study site and the whole HPTN 074 sample, using a 0.5 type I error rate. RESULTS: The response rate were 83.3% and 77.0% at 26(th) and 52(th) weeks. At 26-week, baseline use of over one non-opiate/non-stimulant drug was associated with lower odds of ART use among Indonesian participants (OR = 0.21, 95%CI: 0.05–0.82); and baseline injecting drugs for over 20 days in the previous month was associated with lower odds of ART use among all HPTN 074 sample (OR = 0.59, 95% CI: 0.36–0.97). CONCLUSION: The association of a specific drug use pattern with later ART uptake implies the importance of medication-assisted treatment to enhance ART uptake and adherence among participants.

BACKGROUND: Human Papilloma Virus (HPV), the causative agent for cervical cancer, can be tested for using self-collected vaginal samples. Self-collection is promising for HPV screening in hard-to-reach populations. To assess the relationship between willingness to self-collect and subsequent uptake of self-collection, we conducted a longitudinal study of reproductive-age women in rural Malawi. METHODS: At baseline, we asked women if they would be willing to self-collect a vaginal sample for HPV testing. At follow-up (12–18 months later), we offered the same women the opportunity to self-collect a sample for HPV testing. We examined unadjusted and adjusted associations between baseline willingness to self-collect a sample for HPV testing and uptake of self-collection at follow-up using log-binomial models. RESULTS: Among 122 women who, at baseline, indicated willingness to self-collect, n=65 (53%) agreed to self-collect a sample at follow-up. Of 64 women who stated unwillingness at baseline to self-collect, n=30 (47%) self-collected a sample for testing at follow-up. We observed no association between women’s willingness at baseline and their observed self-collection decision at follow-up (unadjusted prevalence ratio: 1.14, 95% confidence interval: 0.83–1.55). The association remained non-significant after adjustment for age, awareness of cervical cancer, and perceived behavioral control. CONCLUSIONS: Our results suggest that evaluation of acceptability of self-collection should go beyond simply asking women if they would be willing to self-collect a vaginal sample. Given that half of this study’s participants agreed to self-collect a sample when the opportunity was offered, regardless of their previously stated preferences, self-collection should be offered to everyone.

Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services.We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use.Rural Opioids Initiative (ROI) - cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018-March 2020); National Survey on Family Growth (NSFG) - nationally-representative U.S. household reproductive health survey (2017-2019).Women aged 18-49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses.Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations.Of 855 women in the ROI, 36.8% (95% CI 33.7-40.1, unweighted) and 38.6% (95% CI 30.7-47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08-2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95-1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96-1.82]) that did not meet the threshold for statistical significance.WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.

Little is known about the potential mental health impacts of cognitive behavioral therapy and motivational interviewing interventions that focus on alcohol reduction among people with HIV (PWH). Our study aimed to assess the impact of two evidence-based alcohol reduction interventions on depression and anxiety symptoms of antiretroviral therapy (ART) clients with hazardous alcohol use. We conducted a secondary data analysis of data from a three-arm randomized controlled trial among ART clients in Thai Nguyen, Vietnam that evaluated the impacts of two alcohol reduction interventions in Vietnam. ART clients 18 years old or more with hazardous alcohol use (based on the Alcohol Use Disorders Identification Test-Consumption) were enrolled and randomized into one of three arms: Combined intervention, Brief intervention, and Standard of care (SOC). Symptoms of depression, measured with the Patient Health Questionnaire-9, and anxiety, measured with the Generalized Anxiety Disorder-7 scale, were assessed at baseline and 3, 6, and 12 months post-intervention. Generalized estimating equations were used to evaluate the effects of the interventions on depression and anxiety symptoms. The prevalence of depression and anxiety symptoms at baseline was 25.1% and 16.1%, respectively. Decreases in depression and anxiety symptoms were observed in all three arms from baseline to 12-month follow-up. There were no significant differences in depression and anxiety symptoms among participants receiving either intervention, relative to the SOC. Interventions with a dual focus on alcohol and mental health are needed to achieve more pronounced and sustainable improvements in depression and anxiety symptoms for PWH with hazardous alcohol use.

Over the 2018-2019 flu season we conducted a randomized controlled trial examining the efficacy of a Twitter campaign on vaccination rates. Concurrently we investigated potential interactions between digital social network structure and vaccination status.

Background Heavy alcohol use is common among people with HIV (PWH), leading to sub-optimal HIV care outcomes. Yet, heavy episodic drinking (HED) is not routinely addressed within most HIV clinics in sub-Saharan Africa. HIV disclosure may provide social support, potentially reducing HED to cope with HIV. We examined the prevalence of HED and HIV disclosure by antiretroviral treatment (ART) status among PWH receiving HIV care in Cameroon. Methods We analyzed routine HIV clinical data augmented with systematic alcohol use data among adult PWH receiving HIV care in three regional hospitals from January 2016 to March 2020. Recent HED prevalence was examined across PWH by ART status: those not on ART, recent ART initiators (ART initiation ≤30 days prior), and ART users (ART initiation >30 days prior); and by gender. We used log-binomial regression to estimate prevalence differences (PD) between HIV disclosure and recent HED by ART status. Results Among 12,517 PWH in care, 16.4% (95%CI: 15.7, 17.0) reported recent HED. HED was reported among 21.2% (95%CI: 16.0, 26.3) of those not on ART, 24.5% (95%CI: 23.1, 26.0) of recent ART initiators, and 12.9% (95%CI: 12.2, 13.6) of ART users. Regardless of ART status, men were more likely than women to report HED. Those who disclosed HIV status had a lower HED prevalence than those who had not disclosed (aPD: -0.07; 95%CI: -0.10, -0.05) and not modified by gender. Conclusion The prevalence of recent HED was high among PWH in care. HED prevalence was highest among men and recent ART initiators. Longitudinal analyses should explore how HIV disclosure may support PWH in reducing or abstaining from HED through social support. Systematic HED screening and referral to care should be included in routine HIV clinical care, particularly for men, to improve engagement in the HIV care continuum in Cameroon.

Objective Our objective was to quantify the associations between sleep duration and perceived and chronic stress with ideal cardiovascular health (CVH) among emergency medical services (EMS) personnel from county‐based EMS agencies. Methods We conducted a cross‐sectional survey of cardiovascular disease (CVD)‐free EMS personnel from 4 US EMS agencies. The questionnaire consisted of the Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale (PSS), Chronic Burden Scale, and the CVH components (smoking, body mass index, physical activity, diet, blood glucose, blood pressure, cholesterol, each scored 0–2 points). The components were summed and ideal CVH considered 11–14 points. Mixed effects logistic regression models with a random intercept for agency were used to estimate the odds of ideal CVH for good sleep quality (PSQI

Disclosure of one's HIV status may decrease depression and improve the quality of life among people living with HIV. However, there is mixed evidence on the impact of disclosure to partners for pregnant women living with HIV (WLHIV) in areas of intersecting social concerns over disclosure and high prevalence of intimate partner violence (IPV). We assessed the association between HIV disclosure and depressive symptoms among pregnant WLHIV in the Democratic Republic of Congo (DRC) and examined whether the knowledge of partner's status or recent IPV modified this association.We utilized data from participants enrolled in a trial to evaluate the effect of continuous quality interventions on long-term therapy outcomes among HIV-positive pregnant and breastfeeding women in DRC (NCT03048669). Only pregnant women (n = 1392) were included in this cross-sectional analysis. Between November 2016 and June 2019, enrolled participants completed a survey that included the Patient Health Questionnaire-9 (PHQ-9) to screen recent depressive symptoms, questions about disclosure, knowledge of partner's status and IPV. We used linear models to calculate crude and adjusted mean differences (MDs) between disclosure and depressive symptoms. All analyses were stratified by timing of HIV diagnosis.Disclosure was higher among participants diagnosed prior to current pregnancy (41% to their partners and 24% to family, friends or others) relative to those diagnosed during current pregnancy (21% to partners and 12% to family). About one-quarter of women reported any type of IPV in the past 12 months. Disclosure to a partner was associated with lower depressive symptoms among women diagnosed prior to current pregnancy (MD -0.55; 95% CI: -1.06, -0.04) but the opposite was observed among those diagnosed during current pregnancy (MD 0.5; 95% CI: -0.4, 1.4). Adjustment for IPV, knowledge of partner's status, age, number of living children and primigravidae did not change MDs substantially.Women in our sample mostly disclosed to partners despite high IPV burden. The observed association between disclosure to partners and lower depressive symptoms among women diagnosed prior to current pregnancy is consistent with cross-national evidence. A prospective study among pregnant WLHIV is needed to examine longitudinal effects of HIV status disclosure.

Introduction Mental health disorders may negatively impact HIV outcomes, such as viral suppression (VS) and antiretroviral (ART) adherence among people with HIV (PWH) with hazardous alcohol use. This study evaluates the longitudinal association between depression, anxiety symptoms, VS and complete ART adherence among ART clients with hazardous alcohol use in Vietnam; and examines alcohol dependence as a modifier in this association. Methods This was a secondary data analysis of a trial for hazardous drinking ART clients in Thai Nguyen, Vietnam. From March 2016 to May 2018, 440 ART clients with an Alcohol Use Disorders Identification Test‐Concise (AUDIT‐C) score ≥4 for men and ≥3 for women were enrolled. Individuals were randomized to either a combined intervention, a brief intervention or a standard of care. Data on sociodemographics, depression, anxiety symptoms, alcohol use, VS and ART adherence were collected at baseline, three, six, and twelve months. Generalized estimating equation models controlling for intervention exposure were used to estimate time‐lagged associations. Risk ratios were estimated using Poisson regression with robust variance estimation. Results The mean age of participants was 40.2. The majority was male (96.8%), had at least some secondary school education (85.0%) and had a history of injection drug use (80.9%). No overall effect of depression and anxiety symptoms on VS was observed. When stratified by time, increased anxiety symptoms at six months were associated with VS at 12 months (adjusted risk ratio (aRR) = 1.09; 95% CI 1.02 to 1.17). An increase in depression or anxiety symptoms was associated with a decreased probability of complete ART adherence (depression symptoms: aRR = 0.95; 95% CI: 0.91 to 0.99; anxiety symptoms: aRR = 0.93; 85% CI: 0.88 to 0.99). The negative effects of anxiety symptoms on ART adherence were stronger among participants with alcohol dependence, compared to those without. Conclusions Depression and anxiety symptoms had no overall effect on VS, although they were associated with a lower probability of complete ART adherence. Interventions focusing on mental healthcare for PWH with hazardous alcohol use are needed, and integration of mental healthcare and alcohol reduction should be implemented in HIV primary care settings.

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

Female sex workers (FSW) are disproportionately at risk for HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet approaches for incorporating PrEP within prevention strategies used by FSW are lacking. Semistructured focus group discussions were conducted with 44 HIV-negative FSW in Lilongwe, Malawi to explore perceptions of PrEP: acceptability, integration within HIV prevention behaviors, and barriers to use. Acceptability of PrEP was high. Motivation to use PrEP was rooted in love for one's life, anticipated negative economic effects associated with HIV acquisition. PrEP was viewed as complementary to existing norms for engaging in healthy sexual behaviors. Many felt PrEP may provide extra protection from HIV, along with condoms and frequent STI testing. Unpredictable daily lives, stigma, and side effects were barriers that could affect PrEP use. Leveraging existing HIV prevention strategies and social norms surrounding HIV prevention behaviors may positively impact PrEP uptake among FSW in Malawi and sub-Saharan Africa.

Background The United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, primarily of opioids and predominantly in rural areas. Buprenorphine, a medication for opioid use disorder, may indirectly prevent HCV transmission. We assessed the relationship of HCV rates and office-based buprenorphine prescribing in Ohio. Methods We conducted an ecological study of the county-level (n = 88) relationship between HCV case rates and office-based buprenorphine prescribing in Ohio. We fit adjusted negative binomial models between the county-level acute and total HCV incidence rates during 2013–2017 and 1) the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and 2) the number served by office-based buprenorphine (prescribing frequency) from January–March, 2018. Results For each 10% increase in acute HCV rate, office-based buprenorphine prescribing capacity differed by 1% (95% CI: –1%, 3%). For each 10% increase in total HCV rate, office-based buprenorphine prescribing capacity was 12% (95% CI: 7%, 17%) higher. For each 10% increase in acute HCV rate, office-based buprenorphine prescribing frequency was 1% (95% CI: –1%, 3%) higher. For each 10% increase in total HCV rate, office-based buprenorphine prescribing frequency was 14% (95% CI: 7%, 20%) higher. Conclusions Rural counties in Ohio have less office-based buprenorphine and higher acute HCV rates versus urban counties, but a similar relationship between office-based buprenorphine prescribing and HCV case rates. To adequately prevent and control HCV rates, certain rural counties may need more office-based buprenorphine prescribing in areas with high HCV case rates.

BACKGROUND: Ohio’s opioid epidemic continues to progress, severely affecting its rural Appalachian counties—areas marked by high mortality rates, widespread economic challenges, and a history of extreme opioid overprescribing. Substance use may be particularly prevalent in the region due to interactions between community and interpersonal trauma. PURPOSE/OBJECTIVES: We conducted qualitative interviews to explore the local context of the epidemic and the contributing role of trauma. METHODS: Two interviewers conducted in-depth interviews (n=34) with stakeholders in three rural Appalachian counties, including healthcare and substance use treatment professionals, law enforcement, and judicial officials. Semi-structured interview guides focused on the social, economic, and historical context of the opioid epidemic, perceived causes and effects of the epidemic, and ideas for addressing the challenge. RESULTS: Stakeholders revealed three pervasive forms of trauma related to the epidemic in their communities: environmental/community trauma (including economic and historical distress), physical/sexual trauma, and emotional trauma. Traumas interact with one another and with substance use in a self-perpetuating cycle. Although stakeholders in all groups discussed trauma from all three categories, their interpretation and proposed solutions differed, leading to a fragmented epidemic response. Participants also discussed the potential of finding hope and community through efforts to address trauma and substance use. CONCLUSIONS: Findings lend support to the cyclical relationship between trauma and substance use, as well as the importance of environmental and community trauma as drivers of the opioid epidemic. Community-level and trauma-informed interventions are needed to increase stakeholder consensus around treatment and prevention strategies, as well as to strengthen community organization networks and support community resilience.

Purpose To examine the association between sexual minority status and the prevalence of emotional distress and substance use among a nationally-representative sample of youth who reported sexual violence victimization. Methods Data were from the 2017 National Youth Risk Behavior Survey, a biennial school-based survey. We restricted the sample to youth who reported any past-year sexual violence victimization. We estimated prevalence ratios using modified Poisson regression with robust error variance to examine associations of sexual minority status with depressive symptomology, suicidality, and substance use. Results Among the 1364 (9.7%) students who experienced sexual violence, 78% were girls. Relative to heterosexual youth, sexual minority youth had higher prevalence estimates for the emotional distress outcomes and marijuana use. Sexual minority status was associated with depressive symptomology (adjusted prevalence ratio [aPR] 1.33, 95% confidence interval 1.22–1.44), suicidal ideation (aPR: 1.91, 1.66–2.20), medically treated suicide attempt (aPR: 2.74, 1.53–4.93), and past 30-day marijuana use (aPR: 1.29, 1.06–1.57). Conclusions Among youth who experience sexual violence, sexual minorities may experience more emotional distress and substance use outcomes than heterosexuals. Rape crisis programs and other tertiary interventions should attend to the unique needs of sexual minorities who have been sexually victimized.

Background People who inject drugs (PWID) living with HIV experience inadequate access to antiretroviral treatment (ART) and medication for opioid use disorders (MOUD). HPTN 074 showed that an integrated intervention increased ART use and viral suppression over 52 weeks. To examine durability of ART, MOUD, and HIV viral suppression, participants could re-enroll for an extended follow-up period, during which standard-of-care (SOC) participants in need of support were offered the intervention. Methods Participants were recruited from Ukraine, Indonesia and Vietnam and randomly allocated 3:1 to SOC or intervention. Eligibility criteria included: HIV-positive; active injection drug use; 18-60 years of age; ≥1 HIV-uninfected injection partner; and viral load ≥1,000 copies/mL. Re-enrollment was offered to all available intervention and SOC arm participants, and SOC participants in need of support (off-ART or off-MOUD) were offered the intervention. Results The intervention continuation group re-enrolled 89 participants, and from week 52 to 104, viral suppression (, HPTN 074 was an intervention for HIV and opioid use disorder treatment among people who inject drugs living with HIV. In the study extension, viral suppression declined for initial intervention group, yet viral suppression improved for those new to intervention.

The aim of this article is to address how conceptualizations of addiction shape the lived experiences of people who use drugs (PWUDs) during the current opioid epidemic. Using a discourse analytic approach, we examine interview transcripts from 27 PWUDs in rural Appalachian Ohio. We investigate the ways in which participants talk about their substance use, what these linguistic choices reveal about their conceptions of self and other PWUDs, and how participants’ discursive caches might be constrained by or defined within broader social discourses. We highlight three subject positions enacted by participants during the interviews: addict as victim of circumstance, addict as good Samaritan, and addict as motivated for change. We argue participants leverage these positions to contrast themselves with a reified addict-other whose identity carries socially ascribed characteristics of being blameworthy, immoral, callous, and complicit. We implicate these processes in the perpetuation of intragroup stigma and discuss implications for intervention.

Background Opioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID. Methods As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns. Results Despite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators. Conclusion These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Key Points Question What is the effect of 2 clinic-based behavioral interventions of varying intensity on alcohol use and viral suppression among individuals with HIV and hazardous alcohol use? Findings In this 3-group randomized clinical trial involving 440 participants, the combined intervention and brief intervention, which both incorporated motivational enhancement therapy and cognitive behavioral therapy, significantly increased the percentage of days abstinent from alcohol at 12 months compared with the standard of care. Viral suppression at 12 months was significantly higher after the brief intervention than standard of care but not significantly higher after the combined intervention than standard of care. Meaning These findings support the use of the brief intervention in antiretroviral therapy clinics to reduce alcohol use and increase viral suppression in this high-risk population., This randomized clinical trial compares the efficacy of 2 scalable antiretroviral clinic–based interventions on alcohol use and viral suppression among adults with hazardous alcohol use and HIV in Vietnam., Importance Hazardous and heavy alcohol use is common among people living with HIV and may decrease antiretroviral therapy (ART) adherence, but limited data exist from randomized clinical trials about the effects of interventions on viral load. Objective To compare the efficacy of 2 scalable ART clinic–based interventions on alcohol use and viral suppression. Design, Setting, and Participants This 3-group randomized clinical trial was conducted among 440 adults with HIV who were being treated at 7 ART clinics in Thai Nguyen, Vietnam. Adults receiving ART with hazardous alcohol use (Alcohol Use Disorders Identification Test–Consumption score ≥4 for men or ≥3 for women) and no plans to leave Thai Nguyen were included. Data were collected from March 2016 to May 2018 and analyzed from June 2018 to February 2020. Interventions Participants were randomly assigned (1:1:1) to standard of care (SOC), a combined intervention of motivational enhancement therapy and cognitive behavioral therapy (6 in-person sessions of 1 hour each and 3 optional group sessions), or a brief intervention with similar components as the combined intervention but consisting of 2 shorter in-person sessions and 2 telephone sessions. Main Outcomes and Measures The primary study outcomes were percentage of days abstinent from alcohol, confirmed using the alcohol biomarker phosphatidylethanol, and viral suppression at 12 months after enrollment. Results A total of 440 eligible individuals (mean [SD] age, 40.2 [5.8] years; 426 [96.8%] men) were enrolled; 147 (33.4%) were assigned to the combined intervention, 147 (33.4%) to the brief intervention, and 146 (33.2%) to SOC. In the combined intervention group, 112 participants (76.2%) attended all 6 sessions, and in the brief intervention group, 124 (84.4%) attended all 4 sessions; in the whole sample, 390 (88.6%) completed 12 months of follow-up. At 12 months, the mean (SE) percentage of days abstinent was 65% (3.1%) among those in the combined intervention group, 65% (3.2%) among those in the brief intervention group, and 50% (3.4%) among those in the in the SOC group (Cohen d for combined intervention vs SOC and brief intervention vs SOC: 39%; 95% CI, 15% to 64%). Viral suppression (ie

Background People who inject drugs (PWID) bear a disproportionate burden of HIV infection and experience poor outcomes. A randomized trial demonstrated the efficacy of an integrated System Navigation and Psychosocial Counseling (SNaP) intervention in improving HIV outcomes, including antiretroviral therapy (ART) and medications for opioid use disorder (MOUD) uptake, viral suppression, and mortality. There is limited evidence about how to effectively scale such intervention. This protocol presents a hybrid type III effectiveness-implementation trial comparing two approaches for scaling-up SNaP. We will evaluate the effectiveness of SNaP implementation approaches as well as cost and the characteristics of HIV testing sites achieving successful or unsuccessful implementation of SNaP in Vietnam. Methods Design: In this cluster randomized controlled trial, two approaches to scaling-up SNaP for PWID in Vietnam will be compared. HIV testing sites (n = 42) were randomized 1:1 to the standard approach or the tailored approach. Intervention mapping was used to develop implementation strategies for both arms. The standard arm will receive a uniform package of these strategies, while implementation strategies for the tailored arm will be designed to address site-specific needs. Participants: HIV-positive PWID participants (n = 6200) will be recruited for medical record assessment at baseline; of those, 1500 will be enrolled for detailed assessments at baseline, 12, and 24 months. Site directors and staff at each of the 42 HIV testing sites will complete surveys at baseline, 12, and 24 months. Outcomes: Implementation outcomes (fidelity, penetration, acceptability) and effectiveness outcomes (ART, MOUD uptake, viral suppression) will be compared between the arms. To measure incremental costs, we will conduct an empirical costing study of each arm and the actual process of implementation from a societal perspective. Qualitative and quantitative site-level data will be used to explore key characteristics of HIV testing sites that successfully or unsuccessfully implement the intervention for each arm. Discussion Scaling up evidence-based interventions poses substantial challenges. The proposed trial contributes to the field of implementation science by applying a systematic approach to designing and tailoring implementation strategies, conducting a rigorous comparison of two promising implementation approaches, and assessing their incremental costs. Our study will provide critical guidance to Ministries of Health worldwide regarding the most effective, cost-efficient approach to SNaP implementation. Trial registration NCT03952520 on Clinialtrials.gov. Registered 16 May 2019.

BACKGROUND The global scale up of antiretroviral therapy (ART) has significantly improved the immune recovery and life expectancy of people living with HIV (PLHIV). However, PLHIV on long-term ART now face health challenges related to non-communicable diseases (NCDs). We know that exposures such as tobacco, alcohol, diet and exercise are associated with the risk of NCDs. In addition, alcohol is one of the most commonly used substances globally and unhealthy drinking commonly co-occurs with mental health disorders. However, limited data are available in low- and middle-income country (LMIC) settings on the intersection between HIV, NCDs, mental health, and use of alcohol and other substances. As the population of PLHIV increases and ages, it is imperative that we understand the burden of NCDs and risk factors for NCD development as well as their impact on long-term health outcomes.AIMS To establish a network of research sites, the Sentinel Research Network (SRN), and to capture and analyze standardized data among PLHIV in LMICs. Through this network, we further seek to implement studies on cardiovascular risk factors, mental health, alcohol and other substance use disorders, as well as liver disease prevalence/incidence and associated factors among PLHIV accessing care in LMICs.METHODS Create a “sentinel” cohort nested in the pre-existing regional networks of the International epidemiologic Databases to Evaluate AIDS (IeDEA) cohorts based in LMICs. A total of 2, 925 people living with HIV (PLHIV) ≥40 years old and on ART ≥6 months are expected to be recruited at 12 HIV clinics participating in the IeDEA SRN project from the four African regions (East, Central, Southern and Western Africa), Asia-Pacific and Southern America. These participants will be assessed at baseline for various chronic conditions and their risk factors, including diabetes, dyslipidemia, hypertension, drug and alcohol abuse, as well as chronic liver diseases, through standardized questionnaires and non-to-minimally invasive “bedside” screening tests. Follow-up visits are planned at month six, month twelve, month twenty-four and month thirty-six for reassessment of these chronic conditions and also document incident cardiovascular outcomes. Data prospectively collected through the SRN will be merged with pre-existing HIV-related data routinely collected through IeDEA cohorts.EXPECTED RESULTS To date, the IeDEA consortium houses data on nearly 1.5 million adults and 150,000 children and adolescents living with HIV and has been studying treatment and other HIV-related outcomes since 2006. The establishment of the SRN will allow IeDEA investigators to better evaluate additional risk factors and co-morbidities associated with aging and HIV in standardized ways. Through the SRN, IeDEA will also develop the research infrastructure needed to enhance the design and validation of data collection tools related to these co-morbidities.

The aim of the Sentinel Research Network (SRN) is to establish a network of research sites to capture and analyze data among PLHIV in LMICs in a standardized way. Through this network, we further seek to implement studies on cardiovascular risk factors, mental health, alcohol and other substance use disorders, as well as liver disease prevalence and associated factors among PLHIV accessing care in LMICs.To this end, in intend to create a “sentinel” cohort nested in the pre-existing regional networks of the International epidemiologic Databases to Evaluate AIDS (IeDEA) cohorts based in LMICs. A total of six IeDEA research sites located in Brazil, Côte d’Ivoire, India, Kenya, Rwanda and Zambia are expected to recruit a total of 1 375 people with HIV ≥ 40 years and on ART ≥ 6 months. These participants will be assessed at baseline for various chronic conditions and their risk factors, including diabetes, dyslipidemia, hypertension, drug and alcohol abuse, as well as chronic liver diseases, through standardized questionnaires and non-to-minimally invasive “bedside” screening tests. Follow-up visits are planned at month six and month twelve for reassessment of these chronic conditions. Data prospectively collected through the SRN will be merged with pre-existing HIV-related data routinely collected through IeDEA cohorts.The present manual intends to facilitate the implementation of SRN activities at site level. A first part includes information on the preparatory phase and selection of the study population. A second part includes the procedures for recruiting study participants. A third part contains detailed information on the SRN visits including questionnaires administration on alcohol and substance use, mental health disorders, participant’s interview, use of Fibroscan® and biological measures within the framework of the project. Furthermore, a tracing and monitoring process of SRN participants is also proposed in this manual.These procedures should be adapted by each SRN sites according to their specificities as long as they stay in line with the master SRN protocol.

Background: Medication-assisted treatment (MAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient MAT uptake. To expand MAT access and uptake, policy-makers, program-developers and health care providers should be aware of barriers to and facilitators of MAT uptake among PWID. Methods: As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and MAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 health care providers to explore barriers to and facilitators of MAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns. Results: Despite some reported country-specific factors, PWID and health care providers at all geographic locations reported similar barriers to MAT initiation, such as complicated procedures to initiate MAT, problematic clinic access, lack of information on MAT, misconceptions about methadone, financial burden, and stigma towards PWID. However, while PWID reported fear of drug interaction (MAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and MAT. Motivation for a life change and social support were reported to be facilitators.Conclusion: These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand MAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable MAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about MAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and MAT (especially methadone).

BackgroundCross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool—a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.Methods/designThis multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.DiscussionOur results will lay the groundwork for a larger controlled trial that will test the CASPI’s effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.Trial registrationNCT03931005, Registered April 29, 2019.

Background: Cross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool—a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.Methods/Design: This multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.Discussion: Our results will lay the groundwork for a larger controlled trial that will test the CASPI’s effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.Trial Registration: NCT03931005, Registered April 29, 2019, https://clinicaltrials.gov/ct2/show/NCT03931005Contributions to the Literature · Implementing cross-system interventions depends on strong collaboration. Yet, collaborative strategies vary and the conditions under which they are most effective for implementation are unclear. · This study will (1) examine the collaborative strategies associated with implementation of a cross-system intervention that aligns child welfare and substance use treatment systems, (2) develop the Collaborating Across Systems for Program Implementation (CASPI) tool, a flexible decision support for organizational leaders, and (3) pilot test CASPI with organizational leaders. · Our study is intended to advance the effectiveness and efficiency of implementing cross-system interventions by helping leaders identify challenges, and effective collaborative strategies that address them.