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Background Pre-exposure prophylaxis (PrEP) holds promise for decreasing new HIV infections among people who inject drugs (PWID), yet daily oral PrEP use is low, and PrEP modality and delivery strategy preferences in this population remain understudied.Methods From May 2022-June 2023, we conducted a discrete choice experiment (DCE) with PWID in San Diego, California. Participants viewed 18 PrEP program scenarios in sets of three and chose their preferred scenario within each set. Scenarios consisted of various combinations of five characteristics: PrEP modality (injectable, implantable, oral), frequency of use (annual, bi-monthly, daily), service location (community-based organization, clinic, telemedicine), prescription access location (on-site, street outreach, mail), and adherence supports (social support, outreach worker, phone/text reminder). Multinomial logit regression estimated probabilities of choosing PrEP program scenarios as a function of the five characteristics to estimate part-worth utility scores (PWUS; reflecting relative preferences for specific characteristic values) and relative importance scores (RIS; reflecting the relative influence of each characteristic on program choice). We also explored differences by hypothesized modifiers of preferences (i.e., sex assigned at birth, housing status, injection frequency, prior PrEP awareness).Results Among 262 participants, mean age was 43.1 years, and most reported male sex assigned at birth (69.5%), identified as non-Hispanic (60.3%), and were previously unaware of PrEP (75.2%). Frequency of use (RIS: 51.5) and PrEP modality (RIS: 35.3) had the greatest influence on PrEP program choice. Within these characteristics, participants had relative preferences for annual use (PWUS: 0.83) and oral PrEP (PWUS: 0.57), and relative aversions to daily use (PWUS: -0.76) and implantable PrEP (PWUS: -0.53). Generally, participants did not indicate preferences for specific service or prescription access locations, or adherence supports; however, among those with prior PrEP awareness, prescription access location and adherence supports had a slightly greater influence on PrEP program choices.Conclusion Our study considered diverse PrEP scenarios and highlighted potential preferences for long-acting oral modalities. Although not currently available, renewed investment in long-acting oral PrEP formulations may facilitate PrEP care engagement among PWID. Additional delivery and implementation strategy research is needed to support PrEP uptake and persistence in this population.

Background: In the United States, community overdose education and naloxone distribution (OEND) programs have demonstrated efficacy in reducing opioid-related mortality. OEND programs have expanded across San Diego County, California, but differential naloxone accessibility among people who use drugs (PWUD) has not been assessed. We examined factors that shape individual naloxone accessibility in San Diego.Methods: We employed a convergent parallel mixed methods design using surveys (n=194) and qualitative interviews (n=20). Ordinal logistic regression examined factors associated with personal naloxone accessibility (i.e., the frequency with which participants could access naloxone within five minutes, categorized as never, sometimes, or always). Qualitative interviews explored participant perceptions of naloxone accessibility and whether and how they maintained naloxone. We organized multilevel findings into a modified social-ecological model.Results: In quantitative and qualitative samples, participants were majority male (72% and 70% respectively), non-White race/ethnicity (55% and 75%), with an average age around 42 years. In the quantitative sample, 24% never had personally accessible naloxone, 52% sometimes did, and 24% always did. Factors independently associated with greater personal naloxone accessibility were female gender (Adjusted Odds Ratio [AdjOR]: 2.51, 95% Confidence Interval [CI]: 1.31–4.85), monthly income

Human Papilloma Virus (HPV) has a predilection for poly-stratified tissues, with persistence in the basal layers, hence mainly is the etiological agent of cervical cancer. Cervical cancer is the second most common cancer in women worldwide. HPV is unique oncogenic infectious agent that causes it. The objective of the study was to determine the prevalence of the virus in women, using DNA detection techniques through PCR, in real-time, from the cervical biopsy. In addition, the related histopathological and clinical characteristics were established. The prevalence was 30.67%, the most frequently infected histopathology presentation was cervical and in situ cancer. The more dysplastic the histopathology of the cervix, the more frequent the presentation of the virus. An association between exposure to infection and the presence of whitish vaginal discharge and dyspareunia was demonstrated.

BackgroundWe examined HIV prevalence and transmission dynamics among people who inject drugs in the U.S./Mexico border region during the COVID-19 pandemic.MethodsPeople who inject drugs aged ≥18 years from 3 groups were recruited: people who inject drugs who live in San Diego (SD) and engaged in cross-border drug use in Tijuana, Mexico (SD CBDUs), and people who inject drugs in SD and Tijuana (TJ) who did not engage in cross-border drug use (NCBDUs). We computed HIV prevalence at baseline and bivariate incidence-density rates (IR) at 18-month follow-up. Bayesian phylogenetic analysis was used to identify local transmission clusters, estimate their age, and effective reproductive number (Re) over time within the clusters.FindingsAt baseline (n = 612), 26% of participants were female, 9% engaged in sex work, and HIV prevalence was 8% (4% SD CBDU, 4% SD NCBDU, 16% TJ NCBDU). Nine HIV seroconversions occurred over 18 months, IR: 1.357 per 100 person-years (95% CI: 0.470, 2.243); 7 in TJ NCBDU and 2 in SD CBDU. Out of 16 identified phylogenetic clusters, 9 (56%) had sequences from both the U.S. and Mexico (mixed-country). The age of three youngest mixed-country dyads (2018-2021) overlapped with the COVID-related US-Mexico border closure in 2020. One large mixed-country cluster (N = 15) continued to grow during the border closure (Re = 4.8, 95% Highest Posterior Density (HPD) 1.5-9.1) with 47% engaging in sex work.InterpretationAmidst the COVID-19 pandemic and the border closure, cross-border HIV clusters grew. Efforts to end the HIV epidemic in the U.S. should take into account cross-border HIV-1 transmission from Tijuana. Mobile harm reduction services and coordination with municipal HIV programs to initiate anti-retroviral therapy and pre-exposure prophylaxisis are needed to reduce transmission.FundingThis research was supported by the James B. Pendleton Charitable Trust and the San Diego Center for AIDS Research.

BackgroundDomains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages-such as homelessness or drug injection practices-often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel 'MH WASH Domain Scale-12' among people who menstruate and who inject drugs in the Tijuana-San Diego region and identified correlates of MH access using this scale.MethodsWe constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0-12 points and higher scores indicating better MH access. We assessed the scale's reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020-2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates.ResultsAmong 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our 'MH WASH Domain Scale-12' was reliable (Cronbach's alpha = 0.81, McDonald's Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing 'WASH availability' and Factor-2 contained items related to 'WASH security'-encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing.ConclusionWe constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region.

BackgroundWe evaluated the impact of a brief peer-led intervention on COVID-19 vaccination among people who inject drugs (PWID) presenting at syringe services program (SSP) locations in San Diego County, California.MethodsBetween March and July 2022, PWID aged ≥18 years without recent voluntary COVID-19 testing who were not up to date on COVID-19 vaccinations received a single-session motivational interviewing intervention (LinkUP) or an attention-matched didactic control condition from trained peer counselors at SSP sites randomized by week. Following either 30-minute session, counselors offered referrals to local vaccination services. Multivariable log binomial regression via generalized estimating equations assessed LinkUP effects on (1) acceptance of COVID-19 vaccination referrals immediately postintervention and (2) COVID-19 vaccine uptake at 6-month follow-up.ResultsCOVID-19 vaccination outcomes were obtained on 135 (90.6%) of 149 participants. In multivariable analysis, participants receiving LinkUP had greater acceptance of COVID-19 vaccination referrals than controls (adjusted relative risk, 3.50; 95% CI, 1.01-12.2) and were marginally more likely to report receiving a new COVID-19 vaccine dose (adjusted relative risk, 1.57; 95% CI, .99-2.48). After 6 months, 20% reported receiving a new vaccine dose; however, if COVID-19 vaccine had been available at SSPs, this proportion could have been as high as 34.3% (45.3% LinkUP vs 24.3% control; P = .01).ConclusionsA brief peer-led SSP-based intervention significantly improved COVID-19 vaccination among PWID. Further improvements could likely be obtained by supporting SSPs to offer COVID-19 vaccination on-site instead of relying on referrals.Clinical trials registrationClinicalTrials.gov NCT05181657.

BackgroundIn North America, overdose rates have steeply risen over the past five years, largely due to the ubiquity of illicitly manufactured fentanyls in the drug supply. Drug checking services (DCS) represent a promising harm reduction strategy and characterizing experiences of use and interest among people who inject drugs (PWID) is a priority.MethodsBetween February-October 2022, PWID participating in a cohort study in San Diego, CA and Tijuana, Mexico completed structured surveys including questions about DCS, socio-demographics and substance use behaviors. We used Poisson regression to assess factors associated with lifetime DCS use and characterized experiences with DCS and interest in free access to DCS.ResultsOf 426 PWID, 72% were male, 59% Latinx, 79% were experiencing homelessness and 56% ever experienced a nonfatal overdose. One third had heard of DCS, of whom 57% had ever used them. Among the latter, most (98%) reported using fentanyl test strips (FTS) the last time they used DCS; 66% did so less than once per month. In the last six months, respondents used FTS to check methamphetamine (48%), heroin (30%) or fentanyl (29%). Relative to White/non-Latinx PWID, those who were non-White/Latinx were significantly less likely to have used DCS [adjusted risk ratio (aRR): 0.22; 95% CI: 0.10, 0.47), as were PWID experiencing homelessness (aRR:0.45; 95% CI: 0.28, 0.72). However, a significant interaction indicated that non-White/Latinx syringe service program (SSP) clients were more likely to have used DCS than non-SSP clients (aRR: 2.79; CI: 1.09, 7.2). Among all PWID, 44% expressed interest in free access to FTS, while 84% (of 196 PWID) expressed interest in advanced spectrometry DCS to identify and quantify multiple substances.ConclusionsOur findings highlight low rates of DCS awareness and utilization, inequities by race/ethnicity and housing situation, high interest in advanced spectrometry DCS versus FTS, and the potential role of SSPs in improving access to DCS, especially among racial/ethnic minorities.

BackgroundPeople who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic.MethodsFrom September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access.ResultsAmong 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone.ConclusionParticipants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

BackgroundPeople who inject drugs (PWID) have low rates of COVID-19 testing yet are vulnerable to severe disease. In partnership with a mobile syringe service program (SSP) in San Diego County, CA, we developed the evidence-, community-, and Social Cognitive Theory-informed "LinkUP" intervention (tailored education, motivational interviewing, problem-solving, and planning) to increase COVID-19 testing uptake among PWID.PurposeTo assess preliminary efficacy of LinkUP in increasing PWID COVID-19 testing in a pilot randomized controlled trial (RCT).MethodsWe referred participants (PWID, ≥18 years old, San Diego County residents who had not recently undergone voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week) to offer the active LinkUP intervention or didactic attention-control conditions delivered by trained peer counselors. Following either condition, counselors offered on-site rapid COVID-19 antigen testing. Analyses estimated preliminary intervention efficacy and explored potential moderation.ResultsAmong 150 participants, median age was 40.5 years, 33.3% identified as Hispanic/Latinx, 64.7% were male, 73.3% were experiencing homelessness, and 44.7% had prior mandatory COVID-19 testing. The LinkUP intervention was significantly associated with higher COVID-19 testing uptake (p

BackgroundDue to the persistence of COVID-19, it remains important to measure and examine potential barriers to COVID-19 prevention and treatment to avert additional loss of life, particularly among stigmatized populations, such as people who inject drugs (PWID), who are at high risk for contracting and spreading SARS-CoV-2. We assessed the psychometrics of a novel COVID-19 response-related discrimination scale among PWID, and characterized associations between COVID-19 response-related discrimination, resilience to adversity, and endorsement of COVID-19 disinformation.MethodsWe assessed internal reliability, structural validity and construct validity of a 4-item COVID-19 response-related discrimination scale among PWID living in San Diego County, completing interviewer-administered surveys between October 2020 and September 2021. Using negative binomial regression, we assessed the relationship between COVID-19 response-related discrimination and disinformation and the potential moderating role of resilience.ResultsOf 381 PWID, mean age was 42.6 years and the majority were male (75.6 %) and Hispanic (61.9 %). The COVID-19 response-related discrimination scale had modest reliability (α = 0.66, ω = 0.66) as a single construct with acceptable construct validity (all p ≤ 0.05). Among 216 PWID who completed supplemental surveys, a significant association between COVID-19 response-related discrimination and COVID-19 disinformation was observed, which was moderated by resilience (p = 0.044). Specifically, among PWID with high levels of resilience, endorsement of COVID-19 disinformation significantly increased as exposure to COVID-19 response-related discrimination increased (p = 0.011).ConclusionsThese findings suggest that intervening on COVID-19 response-related discrimination may offset the negative outcomes associated with COVID-19 disinformation.

IntroductionWe studied characteristics of COVID-19 vaccination uptake among people who inject drugs (PWID).MethodsParticipants aged ≥18 years who injected drugs ≤1 month ago were recruited into a community-based cohort from October 2020 to September 2021 in San Diego, California Poisson regression identified correlates of having had ≥1 COVID-19 vaccine dose based on semi-annual follow-up interviews through March 15, 2022.ResultsOf 360 participants, 74.7% were male, mean age was 42 years; 63.1% were Hispanic/Mexican/Latinx. More than one-third had ≥1 co-morbidity. HIV and HCV seroprevalence were 4.2% and 50.6% respectively; 41.1% lacked health insurance. Only 37.8% reported having ≥1 COVID-19 vaccine dose. None received ≥3 doses. However, of those vaccinated, 37.5% were previously unwilling/unsure about COVID-19 vaccines. Believing COVID-19 vaccines include tracking devices (adjusted incidence rate ratio [aIRR]: 0.62; 95% CI: 0.42,0.92) and lacking health insurance (aIRR: 0.60; 95% CI: 0.40,0.91) were associated with approximately 40% lower COVID-19 vaccination rates). Ever receiving influenza vaccines (aIRR: 2.16; 95%CI: 1.46, 3.20) and testing HIV-seropositive (aIRR: 2.51; 95% CI: 1.03, 6.10) or SARS-CoV-2 RNA-positive (aIRR: 1.82; 95% CI: 1.05, 3.16) independently predicted higher COVID-19 vaccination rates. Older age, knowing more vaccinated people, and recent incarceration were also independently associated with higher COVID-19 vaccination rates.ConclusionsOne year after COVID-19 vaccines became available to U.S. adults, only one third of PWID had received ≥1 COVID-19 vaccine dose. Multi-faceted approaches that dispel disinformation, integrate public health and social services and increase access to free, community-based COVID-19 vaccines are urgently needed.

The COVID-19 related U.S.-Mexico border-crossing restrictions disrupted social networks and HIV harm reduction services among people who inject drugs (PWID) in San Diego and Tijuana. We assessed associations of descriptive network norms on PWID's HIV vulnerability during this period. Between 10/2020 and 10/2021, 399 PWID completed a behavioral and egocentric questionnaire. We used Latent Profile Analysis to categorize PWID into network norm risk profiles based on proportions of their network (n = 924 drug use alters) who injected drugs and engaged in cross-border drug use (CBDU), among other vulnerabilities. We used logistic and linear regressions to assess network profile associations with individual-level index of HIV vulnerability and harm reduction behaviors. Fit indices specified a 4-latent profile solution of descriptive network risk norms: lower (n = 178), moderate with (n = 34) and without (n = 94) CBDU and obtainment, and higher (n = 93). Participants in higher risk profiles reported more HIV vulnerability behaviors and fewer harm reduction behaviors. PWID's gradient of HIV risk was associated with network norms, warranting intervention on high-vulnerability networks when services are limited.

BackgroundPeople who inject drugs (PWID) are vulnerable to SARS-CoV-2 infection. We examined correlates of COVID-19 testing among PWID in the U.S.-Mexico border region and described encounters with services representing potential opportunities (i.e., 'touchpoints') where COVID-19 testing could have been offered.MethodsBetween October, 2020 and September, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month completed surveys and SARS-CoV-2, HIV, and HCV serologic testing. Logistic regression identified factors associated with COVID-19 testing including potential touchpoints, comorbidities and COVID-19 related misinformation and disinformation.ResultsOf 583 PWID, 30.5% previously had a COVID-19 test. Of 172 PWID who tested SARS-CoV-2 seropositive (30.1%), 50.3% encountered at least one touchpoint where COVID-19 testing could have been offered within the prior six months. Factors independently associated with at least two fold higher odds of COVID-19 testing were living in San Diego, recent incarceration, receiving substance use treatment, and experiencing ≥1 chronic health condition. Homelessness, having received ≥1 dose of COVID-19 vaccine, and having a HIV or HCV test since the COVID-19 epidemic began were also independently associated with having had a prior COVID-19 test.ConclusionWe identified several factors independently associated with COVID-19 testing and multiple touchpoints where COVID-19 testing could be scaled up for PWID, such as SUD treatment programs and syringe service programs. Integrated health services are needed to improve access to rapid, free COVID-19 testing in this vulnerable population.

BackgroundPeople who inject drugs (PWID) face increased risk of SARS-CoV-2 acquisition and severe disease, yet COVID-19 vaccine uptake has been suboptimal. To inform vaccination interventions tailored for the needs of this population, we explored COVID-19 vaccination acceptability and experiences among PWID in San Diego County, USA.MethodsFrom September-November 2021, we conducted qualitative interviews with PWID aged ≥18 years who were participating in a prospective study of infectious disease risks in San Diego. Thematic analysis of coded interview transcripts focused on identifying barriers and facilitators to COVID-19 vaccination.ResultsOf 28 participants, 15 reported having had ≥1 dose of COVID-19 vaccine, primarily received through community health centers, pharmacies, jails, and homeless shelters. We identified three key barriers to COVID-19 vaccination: (1) low perceived risk of COVID-19 (or belief in natural immunity), (2) institutional distrust (e.g., of pharmaceutical companies and government agencies that "rushed" vaccine development, approval, and distribution), and (3) conflicting information from news, social media, and peers. We also identified three key facilitators of vaccination, including (1) heightened personal and interpersonal safety concerns, (2) health service outreach efforts to make vaccines more accessible, and (3) tailored information delivered by trusted sources (e.g., outreach or community health workers).ConclusionsTailored intervention strategies to increase acceptability and uptake of COVID-19 vaccination among PWID should involve efforts to increase vaccine literacy and motivation while decreasing institutional distrust and structural barriers to access.

BackgroundAlong the Mexico-US border, illicitly manufactured fentanyls (fentanyl) have been detected in other illicit drugs, including street opioid formulations known as 'china white.' We studied correlates of recent overdose among people who inject drugs (PWID), focusing on the risk of knowlingly or unknowingly using fentanyl in china white.MethodsFrom October 2020 - September, 2021 we surveyed participants in San Diego, California and Tijuana, Mexico and employed Poisson regression to identify correlates of recent overdose.ResultsOf 612 PWID, most were male (74.0 %), Latinx (71.9 %), US residents (67.0 %). Mean age was 43 years. In the last six months, 15.8 % experienced overdose, 31.0 % knowingly used fentanyl and 11.1 % used china white, of whom 77.9 % did not think it contained fentanyl. After controlling for sex and race, factors independently associated with risk of overdose included knowingly using fentanyl, using china white and not believing it contained fentanyl, recent drug rehabilitation, being stopped/arrested by police, and homelessness. Further, PWID who believed china white contained fentanyl were less likely to use it.ConclusionsBoth intentional fentanyl use and unintentional exposure to fentanyl via china white were associated with overdose risk; however, PWID who believed china white contained fentanyl were less likely to use it. These data suggest that advanced drug checking systems should be implemented to empower PWID to avoid dangerous street formulations or to plan their drug use knowing its contents. Other overdose risk factors such as decreased tolerance following drug treatment, police interactions, and homelessness also require urgent intervention.

BackgroundPeople who inject drugs (PWID) are vulnerable to acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We examined correlates of coronavirus disease 2019 (COVID-19) vaccine hesitancy among PWID in the US-Mexico border region, of whom only 7.6% had received ≥ 1 COVID-19 vaccine dose by September 2021.MethodsBetween October 2020 and September 2021, participants aged ≥ 18 years from San Diego, California, USA, and Tijuana, Baja California, Mexico, who injected drugs within the last month completed surveys and SARS-CoV-2, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) serologic testing. Logistic regressions with robust standard error estimation via generalized estimating equations identified factors associated with being unsure or unwilling to receive COVID-19 vaccines.ResultsOf 393 participants, 266 (67.7%) were willing to receive COVID-19 vaccines and 127 (32.3%) were hesitant (23.4% unwilling and 8.9% unsure). Older participants, those with greater food insecurity, and those with greater concern about acquiring SARS-CoV-2 were more willing to be vaccinated. Higher numbers of chronic health conditions, having access to a smart phone or computer, and citing social media as one's most important source of COVID-19 information were independently associated with vaccine hesitancy. COVID-19-related disinformation was independently associated with vaccine hesitancy (adjusted odds ratio: 1.51 per additional conspiracy theory endorsed; 95% confidence interval: 1.31-1.74).ConclusionsNearly one third of people injecting drugs in the US-Mexico border region were COVID-19 vaccine hesitant, which was significantly associated with exposure to social media, disinformation and co-morbidities and inversely associated with food security and high perceived threat of COVID-19. Interventions that improve accurate knowledge of and trust in COVID-19 vaccines are needed in this vulnerable population.

People who inject drugs (PWID) have extraordinarily low uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) despite high levels of need. Long-acting PrEP modalities hold promise for HIV prevention among PWID, but product preferences remain poorly understood. From September to November 2021, we conducted qualitative interviews with 28 HIV-negative, adult (≥18 years) PWID in San Diego County, CA, to explore their perspectives on daily oral PrEP pills and long-acting PrEP modalities (i.e., injections, implants, intravaginal rings, and broadly neutralizing antibodies), which we explained using standard scripts. Thematic analysis identified variations in PrEP modality interest and acceptability. We identified three key factors across the 28 interviews that appeared to influence PrEP modality preferences: perceived convenience of use, invasiveness, and familiarity (based on past experience). Overall, most participants preferred injectable PrEP over other modalities because they viewed injectable medications as convenient, noninvasive, and familiar. While injectable PrEP was recently approved for use in the United States and was most the acceptable PrEP modality in this sample, our findings suggest that intervention and implementation research is urgently needed to improve our understanding of strategies that could support access, uptake, and sustained adherence to longer-acting PrEP for PWID.

ObjectiveTo document the recovery of vascular services in Europe following the first COVID-19 pandemic peak.MethodsAn online structured vascular service survey with repeated data entry between 23 March and 9 August 2020 was carried out. Unit level data were collected using repeated questionnaires addressing modifications to vascular services during the first peak (March - May 2020, "period 1"), and then again between May and June ("period 2") and June and July 2020 ("period 3"). The duration of each period was similar. From 2 June, as reductions in cases began to be reported, centres were first asked if they were in a region still affected by rising cases, or if they had passed the peak of the first wave. These centres were asked additional questions about adaptations made to their standard pathways to permit elective surgery to resume.ResultsThe impact of the pandemic continued to be felt well after countries' first peak was thought to have passed in 2020. Aneurysm screening had not returned to normal in 21.7% of centres. Carotid surgery was still offered on a case by case basis in 33.8% of centres, and only 52.9% of centres had returned to their normal aneurysm threshold for surgery. Half of centres (49.4%) believed their management of lower limb ischaemia continued to be negatively affected by the pandemic. Reduced operating theatre capacity continued in 45.5% of centres. Twenty per cent of responding centres documented a backlog of at least 20 aortic repairs. At least one negative swab and 14 days of isolation were the most common strategies used for permitting safe elective surgery to recommence.ConclusionCentres reported a broad return of services approaching pre-pandemic "normal" by July 2020. Many introduced protocols to manage peri-operative COVID-19 risk. Backlogs in cases were reported for all major vascular surgeries.

BackgroundPeople who inject drugs (PWID) have low rates of COVID-19 testing and vaccination and are vulnerable to severe disease. We partnered with a local, community-based syringe service program (SSP) in San Diego County, CA, to develop the single-session theory- and evidence-informed "LinkUP" intervention to increase COVID-19 testing and vaccination. This paper details the protocol for a pilot randomized controlled trial (RCT) of the LinkUP intervention.MethodsWith significant community input into study design considerations, including through our Community and Scientific Advisory Board, the LinkUP pilot RCT leverages an ongoing cohort study with adult (≥ 18 years) PWID in San Diego County to recruit participants who have not recently undergone voluntary COVID-19 testing and are unvaccinated. Eligible participants are referred to SSP locations randomized to offer the active intervention (involving tailored education, motivational interviewing, and problem-solving strategies) or a didactic attention-control condition (information sharing only). Both conditions are delivered by trained peer counselors hired by the SSP and were designed to be delivered at mobile (outdoor) SSP sites in ~ 30 min. Intake data assesses COVID-19 testing and vaccination history, health status, and harm reduction needs (to facilitate SSP referrals). At the end of either intervention condition, peer counselors offer onsite rapid COVID-19 antigen testing and COVID-19 vaccination referrals. Out-take and follow-up data (via SSP and state health department record linkages) confirms whether participants received the intervention, COVID-19 testing (and results) onsite or within six months, and vaccination referrals (and uptake) within six months. Planned analyses, which are not powered to assess efficacy, will provide adequate precision for effect size estimates for primary (COVID-19 testing) and secondary (vaccination) intervention outcomes. Findings will be disseminated widely including to local health authorities, collaborating agencies, and community members.DiscussionLessons from this community-based pilot study include the importance of gathering community input into study design, cultivating research-community partnerships based on mutual respect and trust, and maintaining frequent communication regarding unexpected events (e.g., police sweeps, neighborhood opposition). Findings may support the adoption of COVID-19 testing and vaccination initiatives implemented through SSPs and other community-based organizations serving vulnerable populations of people impacted by substance use and addiction. Trial registration This trial was registered prospectively at ClinicalTrials.gov (identifier NCT05181657).

BackgroundPeople who inject drugs may be at elevated SARS-CoV-2 risk due to their living conditions and/or exposures when seeking or using drugs. No study to date has reported upon risk factors for SARS-CoV-2 infection among people who inject drugs.Methods and findingsBetween October, 2020 and June, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month underwent interviews and testing for SARS-CoV-2 RNA and antibodies. Binomial regressions identified correlates of SARS-CoV-2 seropositivity.ResultsOf 386 participants, SARS-CoV-2 seroprevalence was 36.3% (95% CI: 31.5%-41.1%); 92.1% had detectable IgM antibodies. Only 37.5% had previously been tested. Seroprevalence did not differ by country of residence. None tested RNA-positive. Most (89.5%) reported engaging in ≥1 protective behavior [e.g., facemasks (73.5%), social distancing (46.5%), or increasing handwashing/sanitizers (22.8%)]. In a multivariate model controlling for sex, older age, and Hispanic/Latinx/Mexican ethnicity were independently associated with SARS-CoV-2 seropositivity, as was engaging in sex work (AdjRR: 1.63; 95% CI: 1.18-2.27) and having been incarcerated in the past six months (AdjRR: 1.49; 95% CI: 0.97-2.27). Comorbidities and substance using behaviors were not associated with SARS-CoV-2 seropositivity.ConclusionsIn this community-based study of people who inject drugs in the San Diego-Tijuana border region, over one third were SARS-CoV-2 seropositive, exceeding estimates from the general population in either city. We found no evidence that substance use behaviors were associated with an elevated risk of SARS-CoV-2 infection, but observed that circumstances in the risk environment, notably sex work and incarceration, were independently associated with higher SARS-CoV-2 seroprevalence. Our findings suggest that a binational policy response to COVID-19 mitigation is warranted beyond the closure of the U.S.-Mexico border. Furthermore, decriminalizing sex work and drug use could reduce the burden of COVID-19 among people who inject drugs.